Troubling Gifts of Care: Vulnerable Persons and Threatening Exchanges in Chicago’s Home Care Industry

Abstract

By tracing the transformations of troubling exchanges in paid home care, this article examines how differently positioned individuals strive to build caring relations within potentially restrictive regimes of care. In paid home care in Chicago, older adults and their workers regularly participate in exchanges of money, time, and material goods. These gifts play a crucial role in building good care relationships that sustain participants’ moral personhood. Amid widespread concern about vulnerable elders, home care agencies compete in a crowded marketplace by prohibiting these exchanges, even as they depend on them to strengthen relationships. Supervisors thus exercise discretion, sometimes reclassifying gift exchanges as punishable thefts. In this context, the commodification of care did not lead to the actual elimination of gift relations, but rather transformed gift relations into a suspicious and troublesome source of value.

In the summer of 2007, Doris Robinson, a home care worker in suburban Chicago, was fired and prosecuted for stealing upward of $13,000 from John Thomas, one of the older adults for whom she cared.¹ At the time, Mr. Thomas was a retired 95-year-old widower living alone in a modest single-level home in one of metropolitan Chicago’s most affluent neighborhoods. Mr. Thomas had hired Doris through a local home care agency approximately three years earlier, after his wife died. Home care workers like Doris typically assist frail or ill older adults with a range of everyday household and personal care activities ranging from bathing and toileting to grocery shopping, laundry, and cooking. As it turned out, Doris had been borrowing money from Mr. Thomas in one- or two-hundred-dollar increments for much of that time, telling him that she needed the money to repair her car, pay the bills, and care for her family members, including the disabled grandson she was raising while her daughter was incarcerated. Doris told Mr. Thomas that she was unable to work more hours, leaving him with the impression that the agency did not have any additional work for her. Doris had not revealed to Mr. Thomas that she suffered from lupus, or that both her doctor’s recommendation and the work limitations imposed by her social security disability insurance restricted how many hours she could work.

Doris told Mr. Thomas that she would repay the money she had borrowed from him, but given that Doris’s hourly wage was less than $7 per hour, it was unlikely that she would ever be able to do so. Though Mr. Thomas lived frugally, he had more than enough money to keep him comfortable for the rest of his life. He told me later that he and Doris had never agreed on specific terms for the repayment, nor was he particularly concerned about it. The money he loaned Doris had come from the sale of some of his wife’s family’s property, and he had always kept it as cash, separate from his other savings. Mr. Thomas was uncomfortable benefiting from money he had not earned and believed that a few thousand dollars would not be particularly meaningful to his son who had been financially successful enough to retire in his late forties. While Mr. Thomas used the term “loan” to describe this transaction, he also told me he had “given” Doris the money because he was concerned about her family. It seemed that Mr. Thomas was, perhaps from the first exchange onward, unclear as to the status of the exchange and ambivalent about the obligations Doris incurred by accepting it.

Mr. Thomas and Doris kept this exchange secret as the home care agency prohibited gifts or loans between workers and clients. When Mr. Thomas fell ill, his close friend and neighbor discovered a slip of paper hidden on his desk on which Mr. Thomas had written only the dates and amounts of each loan. This unusual form of bookkeeping aroused the neighbor’s concern, since Mr. Thomas otherwise kept meticulous financial records in leather-bound accounting books dating back to before his 65-year long marriage. As the neighbor told me, it took many weeks of probing before Mr. Thomas admitted that the note recorded his illicit loans to Doris. It took several months of additional pressure on the neighbor’s part before Mr. Thomas was convinced to report the loans to the home care agency. Mr. Thomas told me he finally decided to report the loans because he felt betrayed when he learned that the agency would have offered Doris more work hours had she requested them. Doris was immediately fired for stealing money from her client and then prosecuted by the agency’s insurance company to recover the money.

Theft is considered an endemic problem in long-term care settings in the United States, though the prevalence of theft specifically in home-based elder care has been difficult to measure (Harris and Benson 1998; Post et al. 2010). Over the course of two years of ethnographic fieldwork in Chicago’s home care industry from 2006 to 2008, I witnessed or heard about dozens of instances of what people called “theft.” Yet, as with Doris and Mr. Thomas, many of these thefts occurred within a context of ongoing, open, and seemingly voluntary exchanges between workers and older adults. Despite agency prohibitions, direct exchanges proliferated between older adults and home care workers, with elders proffering money, paid time off, hand-me-down clothing, and household goods. Workers reciprocated older adults’ material assistance by providing flexible, empathic care—working extra hours without pay, doing tasks not authorized by agency care plans, and engaging in relations that helped elders maintain familiar domestic economies (Buch 2013). These exchanges played a crucial role in sustaining older adults’ well-being by sustaining their personhood in the face of potentially objectifying care. The exchanges also provided workers with ways of proving their own moral commitments to care while helping them survive and meet commitments to family members on unsustainably low wages. At the same time, these exchanges frequently went awry because of the key role that other powerful actors and institutions played in determining the appropriate boundaries in home care relationships.

In examining these troubled and troubling exchanges, this article seeks to forge a link between two seemingly disparate discussions emerging in the anthropology of care. The first discussion has focused on care as an exercise of diffuse but nevertheless significant forms of power amid the sociopolitical restructurings of neoliberalism and globalization. Miriam Ticktin and others have shown that the purportedly apolitical efforts of humanitarian organizations and social policies enact broad, biopolitical “regimes of care” as they seek to respond to individual traumas and dislocations. These regimes are sets of “regulated discourses and practices grounded on this moral imperative to relieve suffering” (Ticktin 2011:3) that become forms of domination when harnessed by global and governmental neoliberal projects. Regimes of care harness forms of compassion that imagine apolitical suffering subjects—ill and violated human bodies—as removed from the sociopolitical circumstances that produce these conditions (Fassin 2007; Feldman and Ticktin 2010). By individualizing and medicalizing responses to suffering, the apolitics of care practiced in these regimes foreclose possibilities for structural or collective responses to injustice (Ticktin 2011:3).

A second vein of research has focused on the moral and affective aspects of everyday interpersonal care practices. This strand of research conceptualizes care as both culturally variable (Harbers et al. 2002) and a “defining moral practice,” with the potential to make carers “more present and therefor fully human” (Kleinman 2009:293). Focused in part on describing local moral understandings of “good” care, scholars have explored the role of recognition (Taylor 2010), the ongoing “tinkering” carers use to adjust care practices to meet multiple, shifting needs (Mol et al. 2010) and the enactment of “empathic imagination, responsibility, witnessing and solidarity” (Kleinman 2009:293) in care relations. Imagined in this way, care is neither a deployment of or form of resistance against power but “another way of operating in the world” that “pushes against grand narratives of subjugation and exploitation” (Yates-Doerr 2011:154). Yet, while care may draw from distinct logics separate from the logics of power, I argue that care still cannot be adequately understood in isolation from the moral logics and pragmatic operations of power and capital. Rather, comparative anthropological approaches to care require an approach that neither reduces acts of caring to acts of power nor romanticizes care as separate from the fields of power altogether.

Tracing troubling exchanges in home care offers an opportunity to examine both the development of compassionate, moral relationships and the ways that these relations intersect with, enable, and are constrained by institutional structures and processes of capitalism. As new medical technologies transform previously fatal diseases into chronic conditions, ill and disabled older adults have come to require care of unprecedented duration and intensity (Kinsella 2000). Though female relatives have historically provided much of the unpaid care needed by older adults in the United States, their increasing participation in the formal labor force has limited their abilities to continue in this role (Abel and Nelson 1990). Spurred by public policies favoring deinstitutionalization, paid home care has expanded to fill these gaps, and, by the late 2000s, had become one of the fastest-growing occupations in the country (Boris and Klein 2012; Cartier 2003; Lockard and Wolf 2012). As such, the U.S. home care industry is often characterized as representing a significant, if always incomplete, commodification of familial labor and domestic space (Folbre 2008; Hochschild 2003).

Notwithstanding timesheets and care plans that work to alienate home care tasks from care relations, in Chicago, workers and older adults resisted the commodification of care by participating in reciprocal exchanges. As in other contexts in which gift relations persist despite the increased commodification of health care (Andaya 2009; Stan 2012), these exchanges played a crucial role in the ways home care participants established themselves as moral persons and navigated inequality. And, as in other U.S. contexts where intimacy and economy intertwine, in home care gift exchanges are a form of “relational labor” through which people define and contest categories of social relations (Zelizer 2005:28). As Russ notes in her study of hospice workers in San Francisco, categories of commodity and gift are “strategically enacted” by caregivers and “each form of exchange creates unique possibilities for relationality and autonomy” (2005:135).

In Chicago, care recipients also played an active role in the relational labor of home care, proffering a variety of material and immaterial gifts to workers, reminding us that care is not something performed by the able and powerful on behalf of the disabled and disempowered, but an intersubjective relation that requires the participation of multiple parties (Heinemann 2013; Kittay 1996; Mol 2008). In home care, gift exchanges were one way participants assert moral personhood, resisting the potential of commodified home care to make “persons assume the social form of things” (Strathern 1988:134). These gifts, typically prohibited, were nevertheless seen as critical to the provision of good home care, and thus add a troublesome kind of value to market-based home care.

Home care agencies’ viability as commercial organizations depended partly on their workers’ abilities to forge ongoing, trusting relationships that were seen as supporting elders’ ongoing independence. As I argue here, gift exchanges between workers and their elderly clients played a critical role in building and sustaining these relationships. In the messy everyday flow of home care practice, agencies’ dependence on and contradictory need to prohibit gift exchanges was largely mediated by agency supervisors, who drew on both personal and institutional moral values to determine how to respond when they became aware of particular gifts. At the same time, agencies justified their costs based on their ability to protect vulnerable older adults from developing exploitative gift relations with potentially predatory workers, who were, not coincidentally, overwhelmingly poor and disproportionately women of color (Montgomery et al. 2005). Thus, gifts were both necessary and dangerous because of the obligations they forge (Mauss 1990), becoming doubly risky because they could be transformed by the moral evaluations of additional actors empowered by broader bureaucratic and capitalist regimes of care. Attention to the transformations of these troubling exchanges in home care thus offers an opportunity to examine how differently positioned individuals strive to act morally within regimes of care and the ways such moral strivings might engender capitalist value.

The difficulty of removing gift exchanges from market-based home care complicates theoretical distinctions between forms of value in gift versus commodity relations. David Graeber argues that value most broadly is, “the way actions become meaningful to the actor by being incorporated into some larger social totality” (2001:xii). However, most theories of value distinguish between the moral values of social and gift relations and the market value of commodities. According to Anna Tsing, “value in a commodity system is things for use and exchange. Value in a gift system is in social obligations, connections, and gaps” (2013:22). Tsing argues that in contemporary supply chains—one rapidly expanding form of capitalist production— processes like sorting and assessment “make value by purifying” objects of the gift relations that characterize their initial production and thereby transforming them—at least temporarily—into commodities (Tsing 2013:22).

In paid home care, as in other service industries, people and their social relations cannot be purified from service transactions and value inheres to other forms of action. In practice, home care agencies’ value in the marketplace came not from actually preventing gift exchanges but, in part, from performing the moral labor of determining which gift relations were legitimate and ending those deemed inappropriate. By adjudicating the exchange practices through which conflicting moral values about reciprocity and vulnerability were incorporated into market-based care, home care agencies worked to increase their value in a crowded marketplace. The capitalist provision of care in Chicago thus did not lead to the purification of gift relations from commodity exchanges, but rather transformed gift relations into a suspicious, necessary, and troublesome source of market value.

Methodology

Between August 2006 and August 2008, I conducted ethnographic fieldwork with the employees and clients of two home care agencies in Chicago, a city that, for over a century, has been one of the most important laboratories for urban ethnography and scholarship on class, ethnicity, race, and inequality. The first agency, which I call Plusmore, provided no- and low-cost services to poor older adults through a contract with a State of Illinois. The other agency, which I call Belltower, was paid directly by older adults or their families for home care services. Older adults receiving services from Plusmore typically paid a small sliding-scale fee (ranging from $0.35 to $1 per hour) for home care services while the state paid $13 per hour. Belltower clients paid approximately $19 per hour of care received. Plusmore’s workers and clients were overwhelmingly African American women. Belltower, on the other hand, served almost entirely Euro American older adults, while its workers were most likely to be African American, Puerto Rican, or Filipina, though they also employed a sizable number of Polish and West African women. At the time of my fieldwork, Belltower paid workers a starting wage of $6.75 per hour, while Plusmore workers earned a starting wage of $7.65 an hour. Although some benefits and paid leave were available at each agency, very few workers qualified for them.

In agency offices, I observed supervisors’ daily work, training sessions, and staff meetings, learning about hundreds of older adults and workers beyond those I was able to observe directly. Fieldwork also included six to eight months of weekly or bi-weekly participant observation in the homes of four Belltower clients and three Plusmore clients during their home care appointments as well as semi-structured life history interviews with these participants. While observing home care interactions, I alternated between sitting with older adults, usually chatting or watching television, and assisting workers in their regular routines. As a social worker, I was legally required to report evidence of abuse—including financial abuse—to state authorities. Informed consent documents notified participants of this limitation to confidentially. The financial exchanges between Mr. Thomas and Doris were not revealed to me during fieldwork. When I learned of them a year later, after they had been reported to the home care agency, I spoke about them with Mr. Thomas and his neighbor but did not contact Doris, concerned that our conversations could be used against her in legal proceedings.

“You Have to Do Things for Those Who Help You”

In different ways, both home care workers and older adults experienced home care as a source of increased vulnerability that threatened their ability to act as moral persons. For both, gift exchange worked as a potential—if risky and prohibited—safeguard against these threats. U.S. elders experiencing bodily changes that render them dependent on others for care enter a liminal stage in which they are a great risk for becoming unmade as valued persons. As Sharon Kaufman has argued, “in the lives of very old Americans particularly, the ideal of autonomy, understood as unequivocal self-reliance, is pitted against the ever-growing threat of dependence on family, community and the health care system. Aging is conceived of as a battle between discrete and opposing forces of independence and dependence” (Kaufman 1994:47).

For many older adults, paid home care services represented an uncomfortable incursion of market relations into the intimate spaces of their homes. Giving their home care workers gifts was one way that older adults could show that they were still independent subjects. Moreover, by giving gifts, elders established themselves as moral persons who were invested in the well being of the caregivers with whom they spent so much time. For example, Maureen Murphy, a 70-year-old Belltower client, responded to my questions about what kind of care she would want in an ideal world, by saying that, “If I have my senses at all, I’d like to be treated like I have some. I’d like to be treated as a person and not as a piece of furniture.” Ms. Murphy felt that both bodily aging and care threatened to reduce her to an object—to furniture maintained through perfunctory tasks—rather than supporting her subjectivity. Most obviously, Ms. Murphy emphasized, the manner in which she was cared for ought to reflect her continued ability to make conscious decisions for herself and about her everyday life, including decisions about how to value her workers and the care she received.

Gifts helped older adults reverse the relations of dependence that are assumed to come with needing care. Ms. Murphy, barely able to afford Belltower’s pricey services with her retirement savings (which were sufficient to disqualify her from publicly funded services), rarely gave her worker material gifts or paid time off. Instead, Ms. Murphy’s gift to Sally Middleton, her worker, was that she prepared ahead for each of Sally’s visit and tried to be an easy client. As a former nurse, Ms. Murphy was aware of the many ways in which sick and disabled people can care for those who assist them. She was careful to manage her frustration when Sally was late or missed a day’s work due to illness, and tried not to be overly picky about how Sally cleaned, folded laundry, or cooked. Before Sally arrived, Ms. Murphy carefully prepared her shopping list and removed meat from the freezer in time for it to defrost. Though debilitating rheumatoid arthritis caused Ms. Murphy persistent pain, she tried to make Sally’s job easier by staying in an optimistic mood without complaining. To this end, Ms. Murphy told me she valued that Sally “would say enough that would give me the impression that she’s happy what you did for her.” In caring for her home care worker in these ways, and desiring that her caregiver express gratitude, Ms. Murphy sought to establish her continued social value as a caring, generous person rather than the dependent, objectified recipient of caring services.

Older adults often initiated gift exchange in ways that reestablished themselves as independent persons and in so doing altered their apparent position within caregiving relations. Harriet Cole, who had begun receiving care from Plusmore after a stroke she had about a year before we met, argued that the ability to reciprocate care was a hallmark of independence. In one instance, Mrs. Cole told her home care worker Virginia Jackson that rather than purchasing a Christmas gift for her, Virginia should use the money to purchase a gift for Virginia’s boyfriend. Ms. Cole suggested that while Virginia did not depend on her, she did depend on her boyfriend saying, “I don’t matter to you, but he does. You spend that money on your boyfriend who helped you move into a third-story apartment because you need him. So you take that money and spend it on something nice for him.”

In this exchange, Mrs. Cole symbolically gives away her future gift from Virginia, an act of care meant to simultaneously strengthen Virginia’s support system and minimize her own obligations to reciprocate. Mrs. Cole suggested that she already felt burdened by the dependence implied by the debts she had incurred in her need for care. Mrs. Cole told me that despite appearances and the government assessment that indicated her need for care, she did not really need help “that much.” Later, Mrs. Cole told me that she gave Virginia this advice because, “You have to do things for those who help you, because that’s what keeps you independent.” To this end, a few weeks later Mrs. Cole told me that she had given Virginia the day off for Christmas, meaning that she had let Virginia miss the day’s work but still signed her timesheet so that Virginia would be paid for those hours.

Mrs. Cole enjoyed assuming the role of patron and wise elder, regularly giving Virginia hand-me down clothing and household goods as well as advice about how to handle her finances, her daughter, and her boyfriend. Taken together, Mrs. Cole’s declaration of her independence, her gifts and advice produced a striking reversal in which Mrs. Cole asserted that she was a generous, independent person who was caring for Virginia and not the other way around. It was not uncommon that older adults employed both gifts and this kind of maternalist discourse to assert their independence and show that their relationships with workers were at minimum reciprocally beneficial to both parties but at maximum far more valuable to workers. Gift exchange, then, offered older adults an avenue by which to resist the potential unmaking of personhood that threatened to accompany their receipt of home care services. Moreover, gift exchanges offers older adults an avenue to act as caring persons engaged in moral, reciprocal relations with those they depend upon. Through gift exchanges, elderly Chicagoans were able to act in a socially meaningful manner and thus enact their ongoing social value as persons.

“It’s Not about the Money, Baby”

Home care workers’ participation in gift exchange played a crucial role in establishing them as moral persons and carers. In the United States, “separate spheres” ideologies often promote the idea that the sale of care services within capitalist markets necessarily pollutes the authenticity of caring emotions and relationships (Folbre and Nelson 2000; Hochschild 2003; Zelizer 2005). “Caregiver,” the colloquial term used to describe home care workers in the United States, suggests that care itself is widely thought of as inherently a kind of gift. Participants in paid home care generally shared the separate spheres philosophy, but modified it to distinguish between mercenary workers who performed only the care tasks assigned by agency care plans and those who continued to provide care as a gift by doing more than they were assigned. At both agencies, workers were explicitly prohibited from doing work not outlined on the agency-approved care plan, a measure intended to ensure that workers accomplished their work within the designated time and to protect workers from feeling pressured to do inappropriate or dangerous work.²

Home care workers and older adults at both agencies told me that one of the hallmarks of a good home care worker was that the worker was willing to do small extra tasks or work a little longer than scheduled if necessary. Providing only the care permitted by a care plan was taken as a sign that the home care worker approached caregiving as “just a job,” meaning a straightforward exchange of market labor for wages. Bending agency rules and going beyond agency plans to provide care that was responsive to each older adults’ particular needs, habits, and preferences was thus framed as a gift. For example, elder Hattie Meyer spoke with great appreciation for her worker Loretta Gordon, who “would just do anything” and unlike other home care workers would “mop and wax my floor … she’ll put my curtains up. She’ll make my cornbread and okra.” Notably, the former two tasks were prohibited by federally mandated health and safety regulations and agency rules, so Loretta’s willingness to do them was a kind of gift that signaled that her obligations to Mrs. Meyer were more important than her obligations the institution that employed her. Mrs. Meyer recognized Loretta’s extra labor as a gift to be reciprocated, telling me that because Loretta was so willing to do what was asked of her that “if she goes home early, I don’t care.”

Providing flexible, empathic care to older adults enabled workers to act as moral caregivers while also reciprocating the gifts sometimes given to them by older adults. Indeed, it was common that to provide empathic care and protect clients’ routines, workers ended up working extra hours or even extra emergency shifts when needed. When these hours were not pre-approved by the agency, workers were not paid for them. As worker Grace Washington told me,

I’m there with a drop of a hat sometimes 30 minutes before [starting] time. … My hours were supposed to be from 8:00 to 6:10 but I’m not supposed to leave out there until the son walks in there and sometimes he don’t get there until 6:30. I never once put 6:30 or 6:10 on that timesheet. …Over a year’s time, ask me how much time and money that I just gave away. You want to tell me who cares and who don’t care. It’s not about the money, baby. Sometimes you got to do stuff from your heart when you go into these people’s places.

Grace suggests that gifts of time and extra effort distinguish those who truly care about their clients from those who care only because it provides them with a paycheck. Workers’ gifts of time or work that went beyond formal care plans helped them avoid accusations of mercenary motivations by reframing their relationships with clients as altruistic.

Home care workers often felt that their jobs, evaluated as simple wage–labor exchanges, threatened their ability to act as moral persons both in the context of their jobs and family lives. By giving and accepting gifts from clients despite agency rules, workers were better able to meet what they considered their moral obligations to both family members and clients. The home care workers I met financially supported their households and provided a substantial amount of hands-on care for multiple generations of family members: children, grandchildren, and occasionally disabled spouses. Most workers were not eligible for paid sick days or vacation, nor did their jobs provide health benefits. When they or a family member was ill, workers were thus forced to choose between caring for themselves or their families and paying their rent. Workers who missed work with any regularity were fired. Gifts of paid time off offered home care workers the flexibility they needed in these situations, while gifts of money and household goods helped workers support their families.

In the face of ideologies, institutions, and broader structures that threatened to undermine workers’ and older adults’ abilities to act morally, gifts offered both kinds of participants ways of enacting compassionate relationships and moral personhood. In so doing, they resisted the commodifying and objectifying potential of market exchanges, weaving the social obligations and connections that characterize value in gift systems into the capitalist provision of care.

Protective Institutions

Home care agencies depended on home care workers to develop good, caring relationships with their elderly clients. Indirectly, agencies thus depended on the reciprocal ties forged by gift exchange to facilitate these relationships. At the same time, home care agencies’ success in the marketplace was based partly on their ability to protect vulnerable older adults. To this end, agencies prohibited any kind of unmediated exchange between workers and older adults. While these prohibitions were portrayed as essential to protecting home care workers and older adults, they were also an important source of moral and economic value for agencies.

Though Belltower was part of a large non-profit elder-services provider, the agency director and its supervisors were still deeply concerned with attracting new clients and growing the organization. In part, Belltower needed a constant stream of new clients to continue employing its cadre of supervisors and home care workers since the agency lost clients when they moved into institutional care or died. Belltower faced stiff competition for clients from other private full service companies, registry services,³ and independent workers. Belltower’s services were significantly more expensive than the later two business models because Belltower directly employed its workers and therefore had to pay for supervisors, office space, insurance, bonding and employment taxes.

To compete effectively in a crowded field, Belltower’s marketing materials emphasized that the agency protected elders from both the legal and emotional costs of being an employer. When visiting potential new clients in the hopes of convincing them to receive services through Belltower, supervisors focused on several pages in the agency’s information packet that explain the value of the agency’s services. One page included a chart listing differences between registries and full-service agencies, showing that agencies check their workers’ references, conduct criminal background checks, are bonded and insured, have liability insurance, pay all taxes, and conduct supervised home visits. According to the chart, registries did none of these things, though they did charge a commission. In discussing the document with the kin of potential clients—who often play a critical role in the decision to hire a home care agency—supervisors emphasized that the additional services provided by Belltower meant that they, and not elders’ kin, would be responsible for preventing elders from being taken advantage of. Moreover, Belltower supervisors were responsible for the unpleasant work of firing and penalizing workers in the rare cases that such problems occurred. Even as agencies depended on the social obligations and connections forged through gift relations between workers and older adults, they simultaneously needed to prevent exchanges that could be perceived as abusive.

In such a context, unmediated exchanges between workers and older adults posed a potentially existential threat to home care agencies—without the ability to protect older adults, such agencies lost one key justification of their higher costs. The threat of unmediated exchanges impacted a wide variety of agency policies. For example, the agency prohibited workers from discussing how much they earn with their clients. One supervisor suggested to me that this measure was intended to help prevent older adults from worrying about workers’ financial security or feeling like they ought to directly supplement workers’ low wages in the form of gifts. In the handbook the Belltower gave each new worker, eight out of a total of 30 rules on a list describing “unprofessional behaviors that could lead to disciplinary warning or automatic termination” warn workers against participating in a range of exchanges that the agency did not mediate, including: borrowing money, accepting gifts, doing unassigned tasks, stealing, and accepting direct payments for services. According to supervisors, these measures were intended to protect workers from accusations of theft and impropriety as much as they were intended to protect older adults. In the handbook, elderly clients were portrayed as too forgetful or unaware of their actions to participate appropriately in the norms of reciprocity, such that an older adult might “give you something one day and forget by the next day.” While seeking to protect older adults from exploitation, such rules codify beliefs that old age diminishes people’s agentive abilities so that they are not able to appropriately determine what kinds of relationships and obligations they want and ought to have with those around them.

Supervisors at Belltower were generally aware that some illicit exchanges occurred between their workers and clients and understood the critical role these exchanges played in building trusting and caring relationships between workers and clients. In special circumstances, when initiated by the elderly client, the agency authorized reciprocal exchanges between workers and clients provided that the agency mediated the exchange. For example, the agency facilitated the payment of a bonus of several thousand dollars per year that one client offered her live-in home care workers with the understanding that they would arrange their schedules so that she never required another worker. In mediating the exchange, Belltower was also able to formalize and monitor the obligations incurred by both the older adult and her care workers. For Belltower and its supervisors, both their moral responsibility to protect vulnerable elders and the logics of competing in a crowded marketplace required prohibiting unmediated exchanges between workers and clients.

Plusmore’s prohibitions on gifts were motivated by both its concern for protecting vulnerable elders and its fiduciary responsibilities to the State of Illinois. Rather than marketing itself to elders and families to attract new business, Plusmore was assigned clients through its contract with the state. Plusmore took timesheet manipulations extremely seriously, since the state, rather than older adults who signed timesheets for unworked hours, was paying for the unworked time. In one case, I observed Plusmore’s lead supervisor explain to a worker that she was being fired for having turned in a fraudulent timesheet. The worker’s client had signed her entire timesheet for the week on a Monday, but was admitted to the hospital the following Wednesday. Aware of the clients’ hospitalization, her supervisor realized that her worker could not have been caring for her client at home on Thursday or Friday as indicated on the timesheet. When firing the worker, the lead supervisor said that the worker had committed fraud and, in so doing, had tried to steal from both her client (who paid a small co-pay for her care) and the State of Illinois. Supervisors told me that they had a moral and legal responsibility to act as careful stewards of public funds. Moreover, failure to carefully administer public funds would jeopardize the agency’s contract with the state and thus its entire business model.

Due to the needs-based nature of its service, Plusmore’s clients are substantially more economically vulnerable than Belltower clients. Like Belltower, Plusmore prohibited all direct exchanges between workers and older adults. The Plusmore caregiver training manual also forbade workers from consuming clients’ food or drink, purchasing items from the client, assuming control of financial or personal affairs, and asking the client to sign the timesheet before work was completed. In new worker training sessions, the Plusmore head trainer Alicia Morgan told potential new workers to never eat elders’ food because so many clients experienced ongoing food insecurity. Alicia was aware that some elders, motivated by strongly held values around hospitality, would insist on offering workers food. Thus, Alicia emphasized that accepting such meals might cause elders or their families’ real distress. Though aware that refusing elders’ hospitality might create challenges for workers’ attempts to build rapport, Alicia suggested that workers needed to develop the skills to protect elders from the problematic consequences of their hospitable inclinations.

Alicia also told potential workers to be extremely careful to protect themselves from accusations of theft, because in many elders’ households, struggling family members might take money and then blame the worker. The perception that the agency and its workers had to protect both themselves and their clients from elders’ potentially predatory kin arose multiple times, both in the lengthy elder abuse awareness and prevention section of the training, and in more general discussions about how many family members only visited their elderly relatives on “check day,” when their Social Security checks arrived. At Plusmore, the economically vulnerable nature of the client population was widely characterized as creating particular kinds of risks both for elders and their home care workers. At both agencies, prohibitions against unmediated exchanges were seen as a form of care, a way of protecting vulnerable older adults from being taken advantage of, and of protecting home care workers from unfair accusations. At the same time, in both cases, agencies’ abilities to monitor exchanges and protect older adults from some of these risks made them valuable to elders, their kin, and the state.

Troublesome Gifts and Supervisors’ Discretion

To manage agencies’ contradictory position toward gifts, home care supervisors typically adopted a passive stance toward actually enforcing gift prohibitions. Agency staff did not specifically inquire about gift exchanges during phone calls with clients, nor did they seek evidence of such exchanges during home visits. Rather, supervisors relied on elders or their friends and relatives to report exchanges, which nearly always occurred only after workers failed to meet the unspoken obligations such exchanges incurred. Relatives and friends also reported exchanges when they had become concerned or threatened by workers’ growing closeness with older adults. Thus, while the classic literature on gifts focuses on the ways that exchange partners evaluate reciprocal exchanges and obligations, in home care, people outside of the direct exchange play a critical role in such evaluations. Once reported, supervisors were responsible for determining the validity of the report and the appropriate agency response.

Not surprisingly, relatives and friends never complained about a worker giving a client gifts. Notably, I never learned of a case in which an agency punished a worker for providing extra, unpaid care to a client, though this was prohibited by both agencies. Illicit gifts were tolerated when they flowed from worker to client, but not the other way around. For example, in the process of untangling a complicated dispute between a married couple and their two home care workers, a Belltower supervisor learned that one of the workers—an accomplished cook—had agreed to work without pay on her day off so she could bake for the wife’s birthday party. Additionally, the worker had given her colleague misleading information about the couple’s food preferences, leading them to ask the supervisor to replace the colleague. The supervisor believed the first worker was currying favor with the clients in an attempt to push out her coworker and thereby gain more paid hours. In resolving the dispute, the supervisor admonished this worker for offering to work for free and for sabotaging her coworker but did not fire or impose any formal consequence on her.

In some cases, elders’ kin had been participating in gift exchanges with workers as well. One day in fall 2007, I sat with Jackie Wilson, a Plusmore supervisor, as she fielded a lengthy dispute. Problems had started when a home care worker called to tell Jackie that her client’s co-resident son had become very irate and locked her out of the house. According to the worker, the son insisted that the worker was responsible for various household tasks that were not included on his mother’s care plan. For example, the son wanted the worker to clean up after the family dog, wash all the household dishes, and clean the entire house. Jackie immediately called the son and asked him to explain his concerns to her, suggesting that they also review his mother’s care plan so that everyone would be on the same page. Jackie told me that the son defensively explained that none of his mother’s previous home care workers had complained about doing the work he wanted the current worker to do. Jackie spent a great deal of time trying to explain to the son that the home care worker was only responsible for cleaning up after her client, not the entire household. This meant, for example, that the worker should only clean the bathtub after she had given the client a bath and wash the dishes her client had eaten from, but not all the dishes in the sink. In insisting that the son acknowledge and accept the limits proscribed by the agency care plan, Jackie was also insisting that the son could not force her employee to give him a gift of unpaid labor.

Jackie told me that after she explained the limits of the care plan to the son, he made a variety of other complaints about the worker. In particular, the son wanted to know if the worker was still going to get paid for the days when she did not show up for work but he had signed her timesheets. Jackie told me she was suspicious of about this accusation, because the son had never previously mentioned that the worker had missed her appointments. Jackie believed he had only brought it up to strengthen his other complaints about the worker, insinuating that taking care of the entire household was an appropriate return on his gift of paid time off. In this case, Jackie told me that she was so concerned about the son’s motives for telling her about the missed days that she decided not to immediately fire the worker for timesheet fraud. Instead, she replaced the worker with someone she thought would be better able to handle the son, made a note of the incident in the worker’s file, and gave the worker a strong warning about timesheet fraud. Though the worker kept her job, she lost over a weeks’ worth of wages before Jackie found her another suitable case.

Institutionally empowered actors could always redefine gift exchanges between elders and workers as inappropriate or illicit. Yet, as Jackie’s refusal to accept the son’s definition of his mother’s worker as a thief suggests, the success of any effort to define these exchanges depended largely on the person’s position within the broader institutions and regimes of care. Older adults and workers, undermined by their advanced age and employment status, respectively, were rarely trusted to be able to determine whether or not their exchanges were morally appropriate to their relationships. Empowered by agency structures, supervisors were the final arbiters in determining what counted as legitimate and illegitimate exchange. Although supervisors nearly always trusted friends and relatives’ determinations about the appropriateness of exchange, Jackie’s refusal to fully accept the son’s account of events shows that supervisors were also concerned with protecting vulnerable workers from unfair accusations. While workers and clients’ strove to build intimate, compassionate relationships with one another, relatives and friends were frequently suspicious of such relationships. Supervisors were left to determine whether a particular gift exchange, or the relations that encompassed it, placed elders, workers, or the agency at large at too much risk to ignore. Many gifts, especially those that flowed from workers to elders, did not rise to the level of concern but enhanced the agency’s value by building and sustaining the relations associated with good care. Despite agencies’ blanket prohibitions against gifts, only those exchanges transformed by supervisors’ discretion were treated as thefts.

Conclusion

Tracing the ways that people participate in and transform troubling exchanges within Chicago’s paid home care industry illuminates the complex ways that people strive to act morally and compassionately within bureaucratic and capitalist settings. Gift exchanges offered elderly Chicagoans a way to assert themselves as moral agents and independent, caring persons despite increased infirmity. Such exchanges also offered workers a way to prove that their labor was motivated by moral rather than mercenary commitments. These troubling exchanges proliferated in paid home care in part because they are one way that workers and older adults return what they see as the value of caregiving to care work. Home care agencies indirectly benefited from gift exchanges because they were tied to elderly clients’ evaluations of good care and tended to engender more stable and compassionate relationships between workers and older adults.

However, these exchanges occurred within and were animated by broader sociopolitical contexts, within which advanced age and poverty created deep suspicions about the ability of older adults and workers, respectively, to engage in appropriate exchanges. Home care agencies competed in a crowded marketplace in part by promising to protect older adults and the state from being taken advantage of by unscrupulous workers. Supervisors navigated their agencies’ contradictory interests in these exchanges by drawing on their own moral judgments to carefully determine which exchanges could be overlooked and which posed serious threats to clients and thus to the agency. By managing, monitoring, and penalizing these exchanges, supervisors’ own moral evaluations of care relations and exchanges became a source of market value for their agencies. The incorporation of elder care (and potentially other forms of service labor) into capitalist markets does not purify relations of the values associated with gift economies. Instead, gift exchanges proliferate as practices in which multiple parties enact and mediate often-conflicting values. Relations based on social obligation and moral personhood, and the exchanges that sustain these relations, thus become simultaneously constitutive of and subject to bureaucratic ethics and concerns about profitability.

Like other regimes of care, home care tends to individualize concerns about vulnerability and suffering, ignoring key moral and structural concerns. Thus, agency and public policy responses to the most problematic exchanges (e.g., Mr. Thomas’s loans to Doris) focus on penalizing and criminalizing individual home care workers. Workers engage in gift relations with clients as a way of asserting their own and supporting elders’ moral personhood. Criminalizing these exchanges thus has the troubling consequence of diminishing the autonomy and moral personhood workers seek through their labor. Moreover, depicting workers who engage in gift relations with clients as “taking advantage of” elders occludes the ways in which workers are also deeply vulnerable and systematically taken advantage of by the structures of home care and inequality in the United States. By hiding the structures of inequality that generate the need for the biggest gifts, individualized responses to troubling exchanges perpetuate rather than address the actual conditions that create emotional and economic vulnerabilities faced by elders and workers alike.