Care shortages and duties to age abroad

Abstract

Many higher-income countries have shortages of care-workers, which is unlikely to change in the foreseeable future as virtually all of these societies are ageing. The philosophical literature on this problem has concentrated mostly on the merits and demerits of different policy solutions, especially on the recruitment of foreign care-workers and on investments in care robots and other relevant technologies. However, the question of what moral duties, if any, private individuals have to help address care-worker shortages has been entirely neglected. In this article, I help to fill this lacuna by arguing that some inhabitants of higher-income countries have moral duties to age abroad in order to reduce the pressure on the aged care-systems of their current societies, whereby ‘ageing abroad’ is defined narrowly as moving to a foreign country to receive residential or non-residential aged care. As I show, these duties are dependent on a number of conditions being met, including the requirement that the host populations not be made worse off.

Introduction

There are currently large shortages of care-workers within many higher-income countries, including within Western societies on which this article focuses – for Europe, see Ref. 1; for the US, see Ref. 2. Since almost all of these societies are ageing, ³ meaning that the proportion of older adults in the population is increasing, this is unlikely to change anytime soon. The philosophical literature has focused mainly on the merits and demerits of different policy solutions, most notably on the recruitment of foreign care-workers,^4,5 and on the use of care robots and other relevant technologies.^6,7 In my own work, ⁸ I have proposed a different (potentially complementary) policy, namely, that governments of higher-income countries pay their citizens to move to care homes within lower-income countries as long as the care there is adequate and such migration does not harm the health and aged care of local populations. However, no scholarly work has considered what moral duties, if any, private individuals within higher-income countries have to help address care-worker shortages within their respective societies.

This article fills this lacuna by arguing that some of these individuals have a moral duty to age abroad in order to reduce the pressure on the aged care-system of their current society. Insofar as this argument holds, it implies a need to partially reverse existing global care chains, which primarily involve nurses and other aged care-workers migrating from lower-income to higher-income countries to deliver care. By a ‘moral duty’, I here mean a specific type of normative requirement, namely, one that it would be morally wrong not to comply with and that, barring possible exculpating circumstances, renders those who fail to do so liable to blame.^9,10 The term ‘ageing abroad’ is used in a narrow sense to refer to one of two possibilities. The first is that people go live in a care home within another country once they develop a need for aged care. For example, in recent years, several thousand Germans and Swiss are believed to have moved to care homes in Eastern Europe (e.g. Poland, Hungary, Czech Republic), but to a lesser extent also to ones in South-East Asia (e.g. Thailand).^11–13 The second possibility is that they move abroad to receive non-residential aged care within another country, for example, from a local live-in caregiver. A final preliminary is that it is assumed throughout that duties to choose to age abroad can only fall on individuals with normal-range mental capacities, which excludes those suffering from advanced dementia.

To defend duties to age abroad thus understood, I will start by laying out a set of jointly sufficient conditions under which we have duties of beneficence. Next, I will show how each of these conditions is satisfied by at least some members of higher-income countries. The final section concludes.

Jointly sufficient conditions for duties of beneficence

Why think that some inhabitants of higher-income countries have a moral duty to age abroad? Without attempting to provide an exhaustive list of possible grounds, the one I want to focus on here is that doing so is necessary to discharge duties of beneficence (compare Refs. 14,15), defined here as moral obligations to ‘benefit or promote the good of other persons’ that go beyond merely not causing the beneficiaries harm, ¹⁴ which are recognized – I assume rightly – by many prominent moral theories, including most forms of deontology, consequentialism, virtue theory and principlism.^16,17 On my understanding, such duties exist if, and possibly only if, the following conditions are satisfied:

• i. We can confer significant net benefits on others by φ-ing.

• ii. The relevant benefits will not be conferred but by us φ-ing.

• iii. Doing so imposes small costs on ourselves relative to not φ-ing.

• iv. Doing so does not treat any third parties in unjustifiable ways.

Although an in-depth discussion of these conditions is beyond this article’s scope, what is pertinent for our purposes is that they are satisfied in cases where almost everyone will accept that we have duties of beneficence. Consider Peter Singer’s famous case where an infant is drowning in a shallow pond and you are the only person who can save it. ¹⁸ In this scenario, for you to wade into the water to pull the child out of the pond confers significant benefits on the child (i); is necessary to save it (ii); can be done by you at small cost – remember that as the pond is shallow, you do not expose yourself to any danger (iii); and does not treat third parties in an unacceptable manner – no one is wronged by your saving the child (iv). Yet, if duties of beneficence are present in this case as they clearly seem to be, then insofar as we can identify cases where ageing abroad satisfies all these conditions as well, we have good reasons for believing that some of us are duty-bound to age abroad.

Ageing abroad as a duty of beneficence

My next goal is to suggest that there are such cases by showing that for a subset of members of high-income societies, this type of migration is likely to satisfy each of the four conditions mentioned above.

Conditions (i) and (ii)

Whereas I demonstrate in other work how ageing abroad might under certain circumstances benefit members of the receiving societies, ¹⁹ the easiest way of establishing that some people in higher-income countries have duties of beneficence to age abroad is to focus on the benefits involved for those who would remain within their societies. This is both because, all else being equal, our duties towards people in our own countries are generally believed to be strong than those towards people in other countries, ²⁰ and because the potential benefits of ageing abroad tend to be more straightforward for the former. To explain further, it should be observed that in many higher-income countries, a large share of older people is currently unable to live minimally decent lives due to large shortages of care-workers.^1,2 For example, a report by health economist Heinz Rothgang found that, on average, residents of German nursing homes require 141 minutes of care per day but are receiving a mere 99 minutes, ²¹ which is a figure that is unlikely to improve significantly anytime soon. To see this, it should be noted that, like almost every other country in the world, ³ Germany is projected to continue to age in the coming years and decades. ²²

Against this background, for individuals to age abroad can take much-needed pressure off the sending society’s aged care-system and thereby benefit sedentary older populations in meaningful ways, thereby satisfying condition (i). For one thing, when there are fewer people to care for, care-workers will be able to spend more time looking after each individual care-recipient and become less likely to miss work as a result of stress-induced illnesses or burnouts.^23,24 For another, as the workload decreases, so does the risk that high work pressure will cause people to deliver care that is subpar or otherwise defective. ²⁵ (Which, to avoid confusion, does not mean that the staff-to-resident ratio is not the only important determinant of care outcomes; other ones that have been reported in the literature include e.g. staff-education, organizational culture, and managerial stability.)^25,26

A critic might argue that, as imperfect duties, there is no particular manner in which duties of beneficence must be discharged as long the relevant benefits are bestowed. ²⁷ Consider a duty of beneficence to support one’s local community. Such obligations might be discharged in a variety of ways, including by volunteering in the local library, donating money to the local football club, collecting litter in one’s free time, etc., making it difficult to maintain that any one of these measures is specifically required. In a similar vein, our critic might say that duties to help address care-worker shortages within one’s society can be fulfilled in more than one way, thereby undercutting the notion that some of us would need to discharge them by ageing abroad.

I think this is mistaken. Just as the child-drowning case presents us with a scenario in which only one course of action can bestow the benefit in question, namely, pulling the child out of the pond, so ageing abroad appears the de facto only way for many inhabitants of Western countries to significantly reduce the pressure on the aged care-system of their society, thus satisfying the strictures imposed by condition (ii). It may be true that, in principle, members of these societies could reduce this pressure to a similar extent by donating large sums of money to charities like Age UK or the Alzheimer’s Foundation of America (AFA) – and short of committing altruistic senicide, ²⁸ which is not an option for most people and, in any case, not something that can be reasonably expected of them on account of being unduly demanding, ²⁹ such donations seem to offer the only alternative for ageing abroad. However, in reality, most inhabitants of higher-income countries are not in the financial position to make donations of these magnitudes.

Condition (iii)

This brings us to the third condition, according to which ageing abroad should not impose large costs on the would-be emigrants relative to a scenario where they stay within their current society (iii). While such costs will exist for some inhabitants of higher-income countries, as discussed further in the next subsection, this is not true of everyone. To appreciate this, note that due to differences in staff-to-resident ratios, the aged care that inhabitants of higher-income countries with care-worker shortages such as Germany can receive within lower-income countries is often more comprehensive than the one they can receive within their own society. For example, fieldwork by Jill Brütsch shows that in some Thai care homes with German clienteles, residents have at least one care-worker to themselves at any given time. Even if the staff of such care homes are not as well-trained as their German counterparts, at least not formally, ¹¹ it seems that, in many cases, this drawback will be compensated for by the substantially greater time that these individuals can dedicate to their clients, especially when we recall that having large numbers of older individuals to look after tends to compromise the quality of the care. ²⁵ Or consider the care home At the Riverside, which accommodates 59 German residents in the Polish town of Zabelkow. Not only does this care home pride itself on having five to six care-workers for every resident – by comparison, the staff-to-resident ratio for individuals with moderate care needs in Germany is estimated to be 1 to 13 ³⁰ its staff is reportedly at least as well-trained as staff in Germany, if not better, as nursing education in Poland lasts 2 years longer than the Germany equivalent.^12,13 (Although this may not conclusively show the Polish training to be at least as good as its German equivalent – longer does not always mean better – it is highly suggestive, given that 2 years is a significant amount of time.) In a video report by the Rheinische Post, several German residents and their relatives speak highly of how the care home is run. For example, August Schmidt, 82, says that the care-workers are treating him and his fellow residents ‘like their own children’, whereas Horsch Laschet, whose brother lives in At the Riverside, notes that the ‘care is done with more love [liebevoller]’ in a way that is ‘unimaginable within Germany’. (Ref. 31; cf. Ref. 32)

A critic might reply that whether ageing abroad is unduly costly for people is not solely determined by the care to which they have access. It also depends on whether they feel comfortable within their cultural-linguistic environment and social environment. What this means is that even if they can receive superior care within a foreign care home, their chances of living (reasonably) happily might remain higher within a domestic care home insofar as living abroad would expose them to cultural-linguistic differences and/or social differences, most notably reduced contact with relatives and friends, that are likely to undermine their wellbeing and that are absent, or simply not as strong, within domestic care homes.

Two rejoinders are in order. First, given the poor quality of care in many higher-income countries and the much better care available within some lower-income countries (see my previous comments), the cultural-linguistic and social costs of ageing abroad would need to be very high to outweigh these care-related advantages. Second, in a significant number of instances, it is doubtful whether they are high enough.

To vindicate this last claim, I should start by noting that when it comes to cultural-linguistic aspects, the differences between would-be sending and would-be receiving countries are sometimes quite small. For example, many Eastern European care homes that cater to German-speaking clients are situated in regions that were historically home to large ethnic German communities, such as the Sudetenland (now part of Slovakia and the Czech Republic), and despite the displacement and expulsion of large groups of ethnic Germans following World War II, these areas maintain a notable presence of German-speaking populations and cultural influences.^13,33 Yet, even when the local culture and/or language is strongly dissimilar, this still does not always make it costly for individuals to age abroad, or simply not much costlier than ageing within their own society is. Reasons for this may include, without necessarily being limited to:

• - Any cultural and linguistic differences between the would-be sending and receiving countries are hard to notice within the walls of the potential foreign care home, which is true of several Eastern European care homes with German clienteles. Besides having German-speaking staff, many of these facilities celebrate German holidays; serve German food; are equipped with German television and radio; and/or provide German church services.^12,13

• - The aged care-system of the would-be sending country relies heavily on migrant labour, as is common among high-income nations.^34–36 Under these circumstances, any cultural and linguistic barriers that will be encountered within the would-be receiving country need not be (much) greater than those that will be experienced domestically if people decide to stay within their current society, as many caregivers in the latter context will similarly come from divergent cultural and linguistic backgrounds.

• - The potential migrants place relatively little importance on cultural and/or linguistic differences. Such a cosmopolitan attitude is illustrated by a quote from a German resident of the care home in Zabelków, who expresses being ‘indifferent as to whether one is being looked after by a German or Polish caregiver – the main thing is that one is looked after properly’. ³¹

• - The potential migrants are already familiar with the different culture and/or language of the would-be host society. For instance, for Turkish and Moroccan individuals who moved to Germany and the Netherlands as guest workers in the 1970s, relocating to care homes in their countries of origin would represent a return to the cultural and linguistic environment of their upbringing.

Similar things can be said about the social costs of ageing abroad. Not only are these costs sometimes quite modest in absolute terms, there are various cases where they are not significantly higher than the social costs of spending the final part of one’s life within one’s current society. This may be true, for instance, when one or more of the following conditions are met:

• - The foreign care homes to which people can move are situated close to their current place of residence. For instance, many Eastern European care homes with German clienteles are located near the border with Germany. ³⁷

• - There exist affordable, high-quality transportation links between the would-be sending and receiving countries that make it relatively easy and inexpensive for relatives and friends to visit. An example of this is provided by the high-speed train between Vienna and Budapest, which has a journey time of circa 2.5 hours with tickets starting from 12–20 euros as of 2024.

• - People are able to live together with their romantic partner or with close friends or relatives within a foreign care home, but not within a domestic care home due to a lack of capacity.^31,38

• - A shortage of nearby domestic care home places means that people can only keep living within their current society if they move to a domestic care home that is located far from where they presently reside. ³⁹

• - The would-be host society offers more opportunities to socialize with caregivers and fellow care home residents than people’s current society. This is exemplified by the foreign care homes discussed, which boast significantly better staff-to-resident ratios than most German care homes.^31,32

• - Contact with friends and relatives within the would-be sending country can be (partially) sustained through modern forms of communication, such as video-calls.

• - People have little to no friends or relatives who would visit them if they stay within their current country. This is particularly likely when they are only children; when they are childless; when they have reached an age where many of their relatives and friends have died or become incapacitated ⁴⁰ ; when they are Einzelgängers; and/or when they struggle to make (close) friends.

• - People have relatives or friends living within the would-be receiving country, which is especially common when their family originates from that country and/or when they have lived there during previous life stages (see the earlier examples).

The upshot is that there exists a non-trivial range of cases where the cultural-linguistic costs and social costs of ageing abroad do not appear very high, or simply not much greater than they would be were people to spend their remaining years within their current society. When we add to this that the aged care in many high-income countries tends to be poor, while the care available to their inhabitants within certain lower-income countries is often considerably better – which even when the cultural-linguistic and social costs of migrating are substantial may render the overall costs of ageing abroad low to non-existent – it looks like, on the whole, ageing abroad will not be unduly burdensome for a significant group of people in high-income countries. (Whereas some might worry that this group will disproportionally comprise individuals from lower socio-economic classes, it is worth noting that this is far from clear, as certain traits common members of higher socio-economic classes can significantly strengthen one’s moral reasons to age abroad. These traits include, but are not necessarily limited to, possessing a greater cosmopolitan outlook ⁴¹ ; having a higher proficiency in foreign languages ⁴² ; and having (more) friends and relatives with the resources needed to visit one abroad.)

Condition (iv)

Turning finally to condition (iv), there are two prima facie plausible routes through which ageing abroad could end up treating third parties unjustly. The first is that it undermines the interests of members of the receiving societies. One way in which this might happen is that the migrants end up occupying scarce care home places that would otherwise have been occupied by locals. Even if the latter are not formally barred from living in these homes, an influx of relatively wealthy foreigners might make them unaffordable for them by causing rental prices to rise. ⁴³ Another way in which the interests of the host populations might be set back is that such influxes contribute to domestic care-drains and medical brain-drains whereby local care-workers and local medical specialists start offering their services to comparatively rich foreign clients rather than to natives in order to earn more revenue, ³³ which is a phenomenon that has been witnessed in the adjacent context of medical tourism. ⁴⁴ Any such displacements are especially problematic when we consider that the worldwide shortage of nurses is disproportionally concentrated in low- and middle-income countries. ⁴⁵ Still another manner in which host populations might be harmed by the reversal of global care chains resulting from elderly migration is that they miss out on the remittances some of their members would have sent had they been able to provide aged care in higher-income countries.

Although these dangers are important and in need of further scholarly investigation, there seems to me little reason to believe that the effects of this type of migration on the receiving society are more likely to be negative overall than neutral or positive. For starters, when fewer comparatively wealthy inhabitants of higher-income countries move to care homes within lower-income countries, more local aged care-workers and medical specialists are likely to migrate to higher-income countries in order to earn higher wages abroad, as is already happening on a large scale.^46,47 When such care worker-drains and medical brain-drains occur, not only is the care and health care-access of inhabitants of lower-income countries adversely affected as well, ⁴⁸ including that of many stay-behind children of female care-workers who often end up receiving insufficient hands-on care under this type of migration. ⁴ There will generally also be a greater geographical distance between them and their relatives or friends who have migrated abroad compared to a scenario in which the latter had stayed within the country, which imposes substantial social and psychological costs on both groups that would not have arisen, or simply not to the same degree, if older inhabitants of higher-income countries had moved to lower-income countries to receive aged care.^49,50

But that is not all. Since middle- and low-income countries tend to have lower employment rates than their higher-income counterparts, ⁵¹ the supply of aged care-workers is unlikely to remain static if elderly migration from high- to lower-income countries were to take off. A more plausible outcome is for this supply to increase, thereby reducing the risk of locals being deprived of aged care due to care-workers switching from local clients to wealthier foreign clients.

As for the issue of foregoing remittances, we should observe that while receiving remittances can be, and sometimes is, a boon for lower-income countries, ⁵² it is far from clear that the advocated elderly migration is financially less beneficial for these societies. One reason is that for inhabitants of higher-income countries to move to lower-income countries to receive aged care will create many jobs in the latter societies, which is especially valuable considering their comparatively low employment rates (see above). These include not only jobs in local aged care and health care-sectors, but also in construction and hospitality, which are sectors expected to experience further growth because of visits from relatives and friends who, by local standards, will be comparatively wealthy. Another reason is that such migration can help prevent brain-drains in lower-income countries (i.e. emigration of highly skilled and educated individuals) by increasing the odds that registered nurses, geriatric specialists, and professionals in adjacent professions requiring high levels of expertise such as physicians will remain within the country. To see how this may be economically advantageous, it must be noted that brain-drains have a significant negative impact on countries’ average intelligence levels, which a large body of literature indicates are strong contributors to national prosperity.^53–55

The second way in which the advocated elderly migration might treat third parties unjustly is that it gives insufficient weight to the interests of the would-be migrants’ nearest and dearest. My response is that while it may sometimes be wrong for people to age abroad because of the expected impact on these individuals (I leave this for the reader to decide), this is by no means always true. Some of us have few, if any, family members or friends within our current society, or simply not ones with whom we regularly meet. As noted previously, this is particularly likely when we are only children; childless; lone wolves; have reached an age where many of our relatives and friends have died or become incapacitated ⁴⁰ ; and/or struggle to form close friendships. However, even when we do have such connections, it still does not follow that we will be treating our associates unjustly by ageing abroad. Aside from the fact that foreign care homes – but potentially not domestic ones – might allow individuals to live together with their spouse or with specific relatives or friends,^31,38 ageing abroad does not necessarily entail strong social costs for friends and relatives left behind, or simply not significant stronger ones than are incurred when individuals age domestically. Possible reasons that were mentioned include that suitable foreign care homes are located close to people’s existing residences; that there exist affordable and efficient transportation links between the prospective sending and receiving countries; that modern communication methods, such as video-calls, enable continued contact; and that there are either no nearby domestic care homes or none with available places. ³⁹

Finally, as I discuss in more detail elsewhere, ⁴³ even when the social costs for friends or relatives left behind are substantial, there are cases where these costs seem justified based on the interests of (some of) these same individuals and/or the interests of other friends or relatives. One common situation where this may be true is when ageing abroad frees certain friends or relatives from providing extensive informal care to the expatriates, which is often experienced as burdensome by the caregivers. For example, in a 2016 survey from The Netherlands, one in seven unpaid caregivers, who on average provided 28 hours of care a week, reported that the burdens of their caregiving were either ‘heavy’ or ‘too heavy’. ⁵⁶ It might also be true when ageing abroad allows people to live closer to friends and/or relatives already residing in host society, which is especially relevant for those with a migration background (see my earlier comments). In short, even if one believes that we have stringent special duties towards our friends and relatives – which is an issue about which the philosophical literature is divided ⁵⁷ – there exist many realistic scenarios where the impact on these individuals does not seem to prevent people from being under a duty to age abroad.

Concluding remarks

If the foregoing observations are accurate, then all four jointly sufficient conditions for having duties of beneficence to age abroad are likely to be satisfied by at least some members of high-income countries. I want to end this article with a few comments on this finding. The first is that insofar as it is not necessary for all members of high-income countries to age abroad in order to make the aged care-systems of their societies sustainable, any duties to do so might be confined to those of them for whom the net sacrifices of migrating would be smallest. Alternatively, it could be that they all have a duty to age abroad, but that this duty disappears once enough of them have migrated in the same way everyone in a particular are struck by a lethal earthquake might have a duty to donate blood until there is a sufficient supply of blood available – I leave it for the reader to decide which of these alternatives is more plausible.

A second point to make here is that, as care-worker shortages are projected to continue growing in these societies due to population ageing, ³ one would expect this group of duty-holders to expand as a result of two concurrent trends. One is the fact that the societal benefits of such migration are likely to (further) increase. The other is the fact that the net costs for the would-be migrants wane are likely to (further) decrease because of a widening disparity between the quality of care available domestically and that available in certain foreign countries.

A third noteworthy observation – one related to the previous one – is that even if one remains unconvinced that duties to age abroad exist anywhere at the moment, one might still accept that the trends just mentioned, that is, the expected rises in the societal benefits and personal benefits of elderly migration, respectively, are likely to create such duties in the future. According to this view, while the current collective benefits of elderly migration from high-income to lower-income countries may be too low and/or the costs for potential migrants or their nearest and dearest too high, this can be expected to change in the future in ways that will cause some older inhabitants of high-income countries to acquire duties to migrate.

Additionally, or alternatively – and this brings us to the final point – those who do not believe that anyone in high-income countries currently has a duty to age abroad might still endorse one or more of the following moral verdicts, all of which strike me as plausible and as significant in their own right despite being more moderate. They maintain, respectively, that there are compelling moral reasons for inhabitants of higher-income countries to engage in this type of migration; that doing so could be virtuous or praiseworthy in certain cases; and/or that there remains a moral duty for members of this group to seriously consider ageing abroad. If correct, this should further strengthen our reasons for thinking that elderly migration from higher- to lower-income countries is a topic that merits more philosophical and empirical research (of which one important objective will be to gain more clarity of what the likely effects of such migration on both sending societies and receiving societies will be), which I hope this work will inspire.

ORCID iD

Bouke de Vries https://orcid.org/0000-0002-7797-0166