Should Cash Subsidy Be Offered to Family Caregivers for the Elderly? The Case of Hong Kong

Abstract

Hong Kong’s Covid-19 epidemic circumstances have given us a valuable opportunity to reflect on Hong Kong’s elderly care policies. This essay argues that Hong Kong should learn from the West and provide a subsidy to family caregivers for proper elderly care. We rebut the social and moralistic reasons for not introducing such a subsidy in Hong Kong. We indicate that providing cash subsidy to family caregivers does not monetize or tarnish Confucian filial obligation to take care of elderly people, but enable adult children from low-income families to undertake this obligation effectively. In addition, we contend that providing such a subsidy would not significantly affect the job market in Hong Kong and that incurred financial and manpower costs for monitoring family care are controllable.

I

The COVID-19 pandemic has posed enormous challenges to the normal operation of elderly care in every society. According to the U.S. Center for Disease Control and Prevention, older adults are at highest risk for severe illness and death with COVID-19, since the risk for severe illness with coronavirus increases with age. It is noted that “8 out of 10 COVID-19 deaths reported in the U.S. have been in adults 65 years old and older” (CDC 2021). In particular, nursing homes are a precarious situation, as more than one-third of COVID-19 deaths reported in the United States are linked to nursing homes (New York Times 2021). Indeed, the safety and security of institutional care for the elderly has been put in jeopardy in almost every developed region since the outbreak. For example, in Sweden, as of November 2020, nearly half of the more than 6,400 COVID-19 deaths were nursing home residents (Reuters 2020). In Spain, as of February 2021, 29,408 elderly persons living in care homes had died due to the virus (El PAIS 2021). Evidently, elderly people residing in nursing homes and other elderly-care institutions are most vulnerable to COVID-19.

Hong Kong seemed exceptional. Until the fifth wave of the epidemic in early 2022, there had not been any big COVID-19 outbreaks among Hong Kong’s residential care homes and there had not been many confirmed cases among their residents. This success had been achieved through the stringent anti-COVID-19 control measures implemented in each elderly residential institution, including the banning of visits by any non-staff personnel, such as family members (Chow 2021). These measures, however, had generated other severe adverse consequences for older people living in the institutions, such as depression, social isolation, loneliness, decline in physical and cognitive function, and increase in dependency, since many services other than direct care had been suspended (Woo 2020). Although the institutions attempted to tackle such undesirable consequences through alternative methods made available by digital technologies (such as providing interaction with family members facilitated by mobile devices using WhatsApp video calls and transfer of images), the outcome was not satisfactory. It was reported that a “loneliness epidemic” had struck elderly residents, and some of them suffered severe mental problems because they had no chance of meeting their family members for many months (Sun 2021).

In contrast, elderly people staying in their own homes were living in a privileged situation. Although they were also restricted by general anti-COVID-19 measures, such as wearing a facial mask and keeping social distance, they were accompanied by their family members, being able to roughly maintain their habitual manner of life. Evidently, during the COVID-19 epidemic, Hong Kong’s family care for the elderly had not encountered a dilemma that its institutional care had to face: on the one hand, if visits by family members were allowed, infection would be increased so that the security of elderly residents would be compromised; on the other hand, if no visit by family members was allowed, security would be enhanced but elderly loneliness and depression would be inflicted.

It might be argued that the stringent management measures were worthwhile because we had a situation of competing values and had to make trade-offs to protect elderly lives. Unfortunately, due to the occurrence of the highly contagious Omicron variant, even the stringent measures taken to combat COVID outbreaks had to fail. Hong Kong’s so-called fifth wave of COVID epidemic occurred in early 2022. As of 28 March 2022, it had claimed 7,207 lives in Hong Kong: 96 per cent of the death toll was aged sixty or above, and 56 per cent of them were linked to residential elderly institutions (Hong Kong Government 2022). Details aside, the latter figure indicates that Hong Kong’s residential elderly institutions, no matter how stringent their control measures, failed to do better than family care in protecting the lives of elderly people in the COVID pandemic.

This situation suggests that institutional care for elderly people is by no means a preferable option to ageing in place in protecting elderly lives in the pandemic. Indeed, Hong Kong’s anti-COVID circumstances give us a new opportunity to reflect on its elderly-care policy regarding institutional care in comparison with family care. In fact, the government of Hong Kong has long proclaimed the policy of “ageing in place” for older citizens. Its underlying principle has been officially announced as “ageing in place as the core, institutional care as back-up” (居家安老為主，院舍照顧為後援) (Elderly Commission 2017, 14). However, the government has seemed only to give lip service to this principle, without implementing necessary financial and social measures to carry it out. Indeed, the government has invested little in community care services and failed to support family caregivers in order for the elderly to age in place. Instead, the government has heavily funded elderly institutional settings, ending up with the highest elderly institutionalization rate among all countries and regions in the world—approximately 7 per cent of its elderly people (aged sixty-five and older) were living in long term institutional care settings in 2020 (Census and Statistics Department 2022; Social Welfare Department 2022; Woo 2020) (see section II for details).

In this paper we will argue that the government of Hong Kong should offer a cash subsidy to family caregivers to facilitate elderly people continuing to live in their own homes if they so wish. In our view, such a subsidy is much needed. It should be offered for at least three general reasons: it is consistent with the governmental elderly-care principle to support ageing in place, it is a good policy to be learned from the West (as it has operated in a number of Western countries), and it is made even more appealing by Hong Kong’s anti-pandemic circumstances in which elderly residents in institutions suffered not only more psychological stress but also a slightly higher death risk than those ageing at home. By the last point, we do not mean to argue that institutional care is only problematic during the pandemic whereas it is preferable over family care in ordinary circumstances. Instead, it is our view that institutional care for the elderly in Hong Kong is by no means preferable over family care in any circumstances in relation to our policy concerns.1

Before we proceed, it is necessary to clarify two relevant points. First, we do not assume that elderly persons cared for at home are always better off than those cared for in institutions. We fully understand that some elderly individuals need institutional care and prefer such care, and there is nothing wrong in the government supporting institutional care. We also do not think that there is anything wrong for Hong Kong to have the highest elderly institutionalization rate in the world. What we think is problematic is that the government has failed to offer adequate support to community care and to family caregivers, whereas it has funded institutional care enormously. This imbalanced configuration of support is particularly problematic when many elderly people receiving institutional care in Hong Kong actually prefer family care if they have a choice. For example, a survey conducted in 2009 found that 73.5 per cent of the 435 respondents who were receiving long term care services in Hong Kong agreed or strongly agreed that they preferred to receive care at home rather than at a residential institution (Elderly Commission 2009, 24). Without assuming that family care is always better than institutional care for every elderly individual, we hold that it is appropriate that the government to offer financial support for elderly care so that elderly preferences can legitimately be satisfied. Offering cash subsidies to family caregivers is one such way.

Moreover, at the outset it is worth noting that although our discussion is only focused on the Hong Kong regulatory context and moral tradition, it also has broad import for other societies, just as many papers addressing Western regulatory contexts and moral traditions have broad import for other places.2 Cross-cultural learning through a specific focus is beneficial. In the case of Hong Kong, we hold that providing cash subsidies to family caregivers has the potential of assisting those elders preferring home care over institutional care to be able to stay home for their elderly lives. We will also argue that there need not be a conflict between a Confucian moral obligation to care for one’s elders and receiving governmental financial support in order to care for them. Instead, such subsidies can effectively help low-income families to discharge elderly-care responsibilities.

II

In fact, a dozen years ago, a proposal to provide cash subsidies to family caregivers was raised in the government-established Hong Kong Elderly Commission but eventually rejected. Specifically, in 2011, the Commission published a formal report (hereafter the Report) thoroughly addressing the elderly care issues facing the city. The Report has disclosed several crucial features of Hong Kong’s elderly care, and these features, in our view, have remained the same up to the present. In short, in our view, there has not been any essential change in Hong Kong’s elderly care policy since the publication of the Report, and neither has there been any serious challenge made to the conclusions or arguments of the Report, such as its rejection of cash subsidy to family caregivers.

As indicated in the report, in 2008 Hong Kong already had the highest institutionalization rate of elderly people (6.8 per cent) in the world when compared to other countries or regions, such as South Korea (1.1 per cent), mainland China (1.73 per cent), Taiwan (1.9 per cent), Japan (2.9 per cent), Singapore (2.9 per cent), Germany (3.7 per cent), United States (3.9 per cent), Ireland (4.0 per cent), United Kingdom (4.2 per cent), Norway (5.5 per cent), Sweden (5.9 per cent), Switzerland (6.4 per cent), and Netherlands (6.7 per cent) (Elderly Commission 2011, 94). Unaffordable housing price and the lack of household space in Hong Kong may have made ageing in place difficult for the elderly, but these have not been the major factors leading to this highest institutionalization rate. As the report admits, among the major factors that pushed up the institutionalization rate were the inadequacy of subsidized community care services (CCS) and the huge amount of the government welfare support to residential care services (RCS) (see below). RCS are provided by the institutional care homes primarily run by non-government organizations or private operators. In contrast, CCS are provided by both governmental and social agents, including homecare, day-care centres, and social centres for the elderly, but do not provide residential services.

Crucially, residential elderly care in Hong Kong is highly subsidized by the government. For example, government expenditure on subsidized RCS in the 2010-2011 financial year amounted to HK$2549 million (providing 24,746 residential places), while the expenditure on CCS was only HK$381 million (covering 7089 serving places only) (Elderly Commission 2011, 5, 76). The government provides financial support to institutional care in two ways. First, it provides direct subvention to non-government organizations as operators of RCS for elderly people to live in. Moreover, the government offers social security payment through its major welfare programme titled “Comprehensive Social Security Assistance” (CSSA) to the elderly opting for private residential care homes, so that they may use the assistance fund for RCS and thereby live in a private elderly care institution. In this way, the government indirectly provides the elderly with RCS. As a result, as the report admits, “there has been a tendency for older people (or their family members) to opt for RCS instead of CCS,” because not only are there not many CCS resources available for them to use, but they are provided with funding for moving to RCS (Elderly Commission 2011, 43). Indeed, private residential care homes provide about 70 per cent of the total supply of beds in Hong Kong’s institutional care, and a substantial portion of their users are the recipients of the CSSA funding (Elderly Commission 2011, 44). Accordingly, the high institutionalization rate of the elderly and the imbalance between residential care service and community care service expenditures and places have been largely due to the enormous government financial support to institutional care instead of community care.

Ironically, the “ageing in place” policy principle was already set by the government as early as in 1977 (Elderly Commission 2011, 50 –51). The Elderly Commission rightly claims that this principle should be upheld in order to avoid premature or unnecessary institutionalization (Elderly Commission 2011, 41). Indeed, this principle is in line with the wishes of the elderly in Hong Kong. As mentioned before, many elders living in institutions would prefer to live in their own homes given the choice (Elderly Commission 2009, 24). The same preference seems to be held by most elderly individuals in all societies. For example, a survey conducted in the United States in 2004 found that more than 90 per cent of American people aged sixty-five and older wanted to remain in their homes as long as possible (AARP 2012, 48). Such findings align with understandings of basic human nature in which the elderly are generally more comfortable living with their families or continuing to live in a familiar environment than moving to a strange elderly institution. Given the reality of the Hong Kong government’s high financial aid to institutional care and low support to community services, we have reason to suspect that there indeed exists significant “premature or unnecessary institutionalization” in the sense that low-income elderly people have been motivated by governmental financial funds to move to institutional care against their preferences for overall good care.

The Report aimed to advise the government on introducing more flexible modes of financing subsidized community care services. In particular, the Report makes recommendations on three aspects of long-term care provision to strengthen CCS in Hong Kong, namely (i) improving the service provision of subsidized CCS and increasing the service volume, (ii) improving the financial mode, and (iii) creating an environment for further development of CCS (Elderly Commission 2011, 11-38). To improve the financial mode, the Report suggests introducing CCS vouchers based on affordability, shared responsibility, and equitable allocation of resources. It also considers the proposal of “providing cash subsidy to family caregivers so to compensate for their employment income forgone due to caring,” making family caregivers a financially viable option to help their elders to fulfil their preferences to age in place. In our view, such a proposal should have been adoptable and justifiable. Unfortunately, the proposal was turned down in the Report.

The Report marshals three reasons why it should be rejected (Elderly Commission 2011, 277-278). The first is on so-called “social and moralistic grounds”:

It should be reckoned that in Hong Kong there are still the traditional Chinese cultural norms that emphasize the family’s responsibility of taking care of older family members. There might be the concern that the provision of cash subsidy to family members for taking care of their frail older family members might be construed as monetizing and thus tarnishing such traditional virtue

The second reason has to do with the macro-economic implications and the labour market in particular. The Report refers to the experience of the United States to support its concern: “the provision of cash subsidy to family caregivers may turn out to be a disincentive for people to join the workforce and thus would affect the labour market” (Elderly Commission 2011, 277).

Finally, the Report states that “the institution of monitoring mechanisms would inevitably incur financial and manpower costs, which ultimately would increase the financial burden of public services.” Therefore, the Report concludes that “given that there are still controversies as to the desirability and appropriateness of introducing carer subsidy to family carers, there is need to have prudent consideration on the various issues pertaining to such a suggestion” (Elderly Commission 2011, 278).

III

The so-called “prudent consideration” has been conducted for eleven years now but nothing has been done. In the remainder of this paper, we will rebut the above three reasons given in the Report. Our proposal is that the Hong Kong government should offer cash subsidy to family caregivers as a proper incentive for elderly care, even if it is true that families have a special moral obligation to take care of their elderly members, and recognizing that performing such obligation should not be paid in a salary competitive with other occupations in the market. We argue that the provision of such a cash subsidy to family caregivers would not significantly affect the job market in Hong Kong and that incurred financial and manpower costs for monitoring family care are controllable.

The social and moral grounds for rejecting cash subsidy to family caregivers as cited above seem to consist of two reasons: (i) the traditional Chinese cultural norms that emphasize the family’s responsibility for taking care of older family members are still present and functioning in contemporary Hong Kong society, and (ii) the provision of cash subsidy to family caregivers for taking care of their older family members might be construed as monetizing and thus tarnishing the traditional virtue of filial piety.

We think reason (i) cannot be drawn on to reject the provision of cash subsidy to family caregivers. It is true that most Hong Kong people are still committed to the traditional Confucian virtue of filial piety and taking care of their elderly parents and grandparents in physical, psychological, and/or financial ways. They still believe that they bear a moral responsibility to do so. However, we think the vitality of such family responsibility in Hong Kong society precisely calls for providing financial subsidy to family caregivers in low-income families, because they need the economic support in order to fulfil the responsibility. A caring role under this responsibility is very demanding and the care of family members may come at a significant cost in lost income and employment opportunities. Of course, upper and middle-income families have resources to hire domestic helpers to do the caring work. According to Hong Kong government statistics, the number of households employing domestic helpers increased from 212,500 in 2000 (about 10.1 per cent of all households) to 355,700 in 2019/20 (13.4 per cent) (Census and Statistics 2021). However, low-income families cannot afford to hire domestic helpers. It is not that they reject the cultural norm of filial piety and the practice of looking after their elder members who wish to live in their own home rather than move to an institution, but that they are unable to do so without necessary economic subsidies. In addition, they cannot enjoy tax allowances as middle and upper-income families can (see section IV).

In fact, various forms of income support to family caregivers can be found in countries like Australia, Canada, Ireland, Sweden, the United Kingdom, and the United States. For example, in Canada, the Newfoundland and Labrador’s Paid Family Caregiving Option was introduced in 2014 as a pilot scheme and was approved as a permanent option after evaluation. Under this scheme, subsidies to eligible elderly are provided so that they can pay a family member for approved home support (Newfoundland Labrador Health and Community Services 2015). In Australia, an income support payment called “Carer Payment” provides financial assistance to eligible carers who are unable to support themselves because of the demands of their daily care for someone who has a disability or serious illness or is frail aged (Australian Government 2021). It is subject to income and assets tests. If carers are in employment and their income level reaches the prescribed level, the payment will be reduced. If carers earn more than the upper level of the income test, the payment will stop. Carer Payment also covers non-relative carers and carers who do not live with the care receiver. In addition, a supplementary financial assistance called “Carer Allowance” provides income support to carers who provide daily care at home. Carer Allowance is not taxable or subject to income and assets tests. In 2007, there were 116,614 recipients of Carer Payment, and two-thirds of them were female and more than one third were aged between fifty and fifty-nine years. Only 13 per cent of the recipients had their payment reduced because their income from employment reached the prescribed level of income. There were 393,263 recipients of Carer Allowance in 2007. Over half of the recipients also received other income support payment such as Carer Payment or Age Pension, Parenting Payment, or Disability Support Pension (Australian Government 2008).

In the United Kingdom, a cash award scheme allows an eligible care receiver to opt for cash payment instead of care services so that one can pay their own family member to do the care (Carers UK 2014). The Carer’s Allowance covers non-relative carers and carers who do not live with the care receiver. The allowance is usually below the threshold for paying income tax, but carers who receive the allowance will have to pay tax if they have other sources of taxable income. In the United States, a care receiver can hire a family member (including spouse) as caregiver and pay for the care services received under the Cash and Counseling Program.3

There must be some people in these Western countries still believing and practicing their traditional norms (such as the Judeo-Christian Commandment of “honouring your father and mother”) and undertaking the family’s responsibility of looking after older family members. But the availability of such traditional Western norms has not negatively affected their governments’ decision in setting up subsidies to family caregivers. Accordingly, such Western policies are heuristic to Hong Kong. It is unreasonable to exaggerate “differences” between Western countries and Hong Kong in this regard. Even if more people in Hong Kong than in the West still uphold traditional virtues for the family responsibility, this should not be relevant to the legitimacy of providing a subsidy to family caregivers. For the crucial issue is that Hong Kong should provide such assistance in order to follow its principle of ageing in place as the core, even if families also have moral responsibility to take care of their elderly members. When low-income families are unable to discharge such a responsibility without subsidy, society is justified to provide it, as long as there is no other compelling reason against such provision.

IV

Some may take reason (ii) listed in the Report as constituting such a compelling reason. The central idea of reason (ii) seems to be that the exercise of virtue and cash subsidies for elderly care are incompatible. This idea implies that providing cash subsidies to family caregivers monetizes the traditional Confucian virtue of filial piety, thereby dulling or even destroying the exercise of virtue in Hong Kong society. Accordingly, it concludes that although Western liberal countries may provide such cash subsidies, Confucian Hong Kong should not.

Indeed, while contemporary liberal culture holds that adult children do not have a moral obligation to take care of their elderly parents because they have never agreed to be born in the world and discharge such obligation (English 1992; Daniels 1988), Confucian culture has long emphasized the virtue of filial piety (xiao), upholding such obligation as heavenly mandated or naturally given without the need of any contract to be made. Indeed, Confucian filial piety is not grounded in any man-made contract but is understood to be originated from the Way of Heaven —a manifestation of natural principles for worldly righteousness and for guiding proper human lives and relations (Legge 2010). In the Confucian view, most general and complete Confucian virtue is ren (benevolence), and ren is taken to be rooted in filial piety. Confucius points out in the Analects: “the gentleman devotes his efforts to the roots, for once the roots are established, the Way will grow therefrom. Filial piety and fraternal care are the root of ren” (Analects 1.2). In Confucian tradition, ren is primarily meant for “loving people” (Analects 12.22). However, ren as love does not advocate absolute egalitarian love, but rather differentiated and graded love; namely, that one should love one’s parents and immediate family members more than other people. As Mencius indicates, “one’s capacity of love is not naturally directed to everyone with equal intensity. Your affection for your brother’s baby is not like your affection for a neighbor’s baby, and is rightly so” (Mencius 3A5). Thus, Mencius sometimes stresses that ren is equivalent to loving one’s parents (Mencius 7A15). In the Confucian classic of filial piety, it is clearly stated that “those who do not love their parents but love others are violating virtue; those who do not respect their parents but respect others are violating the rites” (The Classic of Filial Piety 9).

Indeed, in the Confucian view, since everyone is born and grown in the family, love (as the function of the virtue of ren) must be started and learned from the family. Without being able to learn and practice the loving of one’s immediate family members, especially one’s parents, one will not be able to learn and practice the loving of other people. As a result, Confucianism stresses that love should be started from and cultivated in the family and be extended to other people outside the family. As Mencius states, “Treat with respect the elders in my family, and then extend that respect to include the elders in other families. Treat with tenderness the young in my family, and then extend that tenderness to include the young in other families” (Mencius 1A7); “A person of ren extends his love from those he loves to those he does not love” (Mencius 7B1).

It has been generally noticed that Confucian filial obligation towards one’s parents consists of three aspects of work: taking care of their physiological needs, taking care of their mental lives and making them happy, and taking care of their spirits after they die. Moreover, such work should be conducted and guided in terms of Confucian rituals or rites. As Confucius requires, “When your parents are alive, comply with the rites in serving them; when they die, comply with the rites in burying them and in offering sacrifices to them” (Analects 2.5). Finally, in the process of exercising the rituals and performing such work of care, adult children must adopt the important attitude of respect (jing) towards their parents: “those who are considered filial these days are those who are able to provide food to their parents. However, even dogs and horses are, in some way, provided with food. If one shows no respect, where is the difference?” (Analects 2.7).

This long-standing Confucian ethic of filial piety is still vibrant in Confucian-influenced East-Asian societies, including Hong Kong (Cheung and Chow 2006; Li 1997; Nie 2015; Qiu 2004; Yu 2007; Yung 2015). This ethic has significant policy implications. Scholars have argued that Confucian filial obligation should be adopted to formulate appropriate long-term care policies for elderly people in these societies, and such policies should be made in ways in which adult children are encouraged, facilitated, and assisted to exercise this virtue and take care of their elderly parents (Wang 1999; Chong et al. 2006; Chong and Liu 2016; Engelhardt 2007; Fan 2006 and 2007; Tao 2007; Chow and Ho 2014). As mentioned above, the Report acknowledges that the elderly in Hong Kong prefer to live in their own home rather than in an institution (Elderly Commission 2011, 43) and Confucian filial obligation and respect would require adult children to give assistance to their elderly parents for them to live in their own home if they so wish. When low-income families do not have finance or space to hire a domestic helper to meet this need, the only option would be for an adult child or other relative to stay with the elderly and offer needed care. But this child or relative would need a subsidy to support them in order to do so. Should the government offer such subsidy? Does it, if offered, monetize the virtue of filial piety as reason (ii) charges?

We think this charge is untenable. Properly provided cash subsidies to family caregivers cannot change the moral nature of the obligation under the virtue of filial piety. No doubt, “monetizing” is often a derogatory term. When one says “monetizing something,” it is usually meant that one wants to make money from it, or that one wants to express its nature in terms of money or currency when one should not. However, when cash subsidy is properly set at an amount lower than the market price of similar work for an adult child or relative to care for one’s parent or an elderly relative at home, he or she would hardly be motivated by a “money-making” intention to undertake the care work under such subsidy arrangement, because such an intention would be satisfied much better by doing something else in the market. Moreover, caring for the elderly is by no means an easy or interesting task. It engages tedious routine work and requires the spirit of love, care and dedication as well as enthusiastic and constant efforts. Provision of a small amount of cash subsidy to family caregivers by no means changes the expression of the moral nature of such work into that of money or currency.

Finally, although there is no such subsidy offered currently in Hong Kong, the government offers tax allowances under the Additional Dependent Parent and Dependent Grandparent Allowance policy to encourage adult children to give financial assistance to their parents or grandparents. Under this policy, eligible taxpayers can claim the basic Dependent Parent and Dependent Grandparent Allowance for each dependent parent or grandparent (Inland Revenue 2022). Moreover, adult children who live with their dependent parent or grandparent can claim the Additional Dependent Parent and Dependent Grandparent Allowance, which is the same amount as the basic Dependent Parent and Dependent Grandparent Allowance. As a result, an eligible adult child who lives with a dependent parent or grandparent can claim twice more allowance than another person who does not live with his or her dependent parent or grandparent. In 2018, the total labour force in Hong Kong was 3.98 million and only 47 per cent of the working population were required to pay salaries tax (Inland Revenue 2019). Such tax papers must belong to middle- and upper-class people in Hong Kong. Although we cannot find a formal figure about how many taxpayers claim such allowances, we trust that the figure is big. Obviously, such allowances do not benefit two million low-income employees nor other unemployed people. If such tax allowances do not monetize the virtue of filial piety on the part of middle- and upper-class children (as we believe they do not, because such children could still gain more money for themselves if they do not offer financial assistance to their parents or grandparents), cash subsidy to family caregivers for the low-income group does not either.

Indeed, teachers, social workers, and civil servants (including policemen and firefighters) are all paid for their work. The monetary reward does not compromise the moral obligation borne by such work. Although familial obligation is a special moral obligation that does not arise from a contract for profit, society should offer a subsidy to family caregivers as a proper support and incentive for low-income families to be able to discharge the obligation. It can be construed as playing the same function as the above-mentioned tax allowance for middle- and upper-income families to support their parents and grandparents. As long as such subsidy is set at a lower rate than the salary of a relevant job in the market, it can help to ensure that the primary motive of a family caregiver is filial piety, love, and respect for their elders, rather than making money.

Nevertheless, some may contend that even if cash subsidy does not monetize the virtue of filial piety, it may still tarnish the virtue in other ways, as the Report seems to suggest. First, they may argue, isn’t it likely that providing cash subsidy would generate free riders so as to corrode the virtue? That is, some adult children may apply for the cash subsidy to gain the “available” money, but they will not actually do the work of taking care of their elderly members (just as they have no interest to do any useful work in the market to support themselves, either). In this way, they may conclude, the society would have paid the financial cost for these individuals in vain while the virtue of filial piety is corrupted. Of course, we cannot exclude the possibility that there will be, no matter how few, such free riders in Hong Kong society, just as any financial arrangement may have to face this problem. However, the possible damage of such free-rider behaviour on the virtue of filial piety can be prevented or reduced through appropriate designment, management, and supervision of cash subsidy provisions in the society. In this regard, Hong Kong should learn from the experiences of other countries in adopting certain checks and balances applicable to the provision of carer cash subsidy. For example, in Australia, fraudulent carer’s payments can be reported to the police and will be investigated as welfare fraud (Australian Government 2021). In Ireland, fraudulent carer’s payments will be investigated and, if persecuted, will lead to sentencing and compensation to the state (Heylin 2021).

In addition, the virtue of filial piety may be dulled in another way in the eyes of objectors. In Chinese society, it is admirable and honourable to offer good care to one’s elderly parents and grandparents without seeking any financial benefit. It is also claimed that in traditional societies only honorary but not economic incentives were offered to reward the virtue of filial piety. Thus, the objectors may conclude, if certain cash subsidies are offered to family caregivers, the honourable meaning of care work would be discounted, and family caregivers may even be seen as conducting the work for the sake of money rather than love or virtue, so that they will fear ill-reputation and thereby will not apply for such subsidies. As a result, the subsidy policy will not encourage suitable children or relatives to become family caregivers, thus the traditional virtue will be ill-served and even stained.

We do not think this is likely to happen. First, it is a misunderstanding that traditional Confucian societies offered only honorary incentives but not economic or financial ones to encourage filial piety. True, Confucian tradition upholds honouring elderly people in general ritual performance and praises those children who take good care of their older family members. But it is also true that governments offer economic facilities to families with older members. For example, in the Confucian classic of rites (Liji), it is recorded that Confucian sages not only used ceremonial rituals to nourish and entertain elderly persons, but also formulated assisting regulations to help families in taking care of their elders: for instance, if a family has an eighty year old, one of the sons would be free from all duties of government service; if a family has a ninety year old, all family members would be free from such duties (Liji 5). Throughout traditional Chinese dynasties, there have always been relevant statues and regulations that offer tax allowances or relieve governmental levies for families with elderly members (Tang and Chan 2014, 68–94). In short, people in traditional Confucian societies have never held that giving certain economic or financial support to families for looking after their elderly members would discount the honourable meaning of their care work so as to stain the virtue of filial piety.

Moreover, contemporary societies differ from traditional agricultural ones in the delivery of elderly care. In traditional societies, families conducted agricultural work and lived near the farm to do the work. If governments refrained from levying their young members from the family, they could care for their elders while conducting their work, without suffering work–care imbalance. Accordingly, relieving families from governmental levies would be an enormous help in traditional society. In contrast, the employment setting of contemporary society is much more demanding on employees, who will normally have to commute to work on fixed time schedules, and overtime work is a commonplace. As a result, the incompatibility between work requirements and family obligations becomes the root of many social problems, including parental neglect or poor parent–child relationships.4 Accordingly, offering cash subsidies to low-income families for elderly care in contemporary society is in a sense analogical to relieving governmental levies from families in traditional society: one is thereby able to stay home and take care of one’s elderly parents or grandparents. With such subsidies, some individuals from low-income families would be able to take care of their elderly relatives at home, without having to work in the market for an income. They will still be honoured rather than ill-reputed because they will be understood as giving up a better salary for taking care of their elders at home. The honourable meaning of their care work cannot be depreciated.

V

In addition to the worries about the erosion of the virtue of filial piety, the Report mentions two other negative implications that may likely be generated by the provision of cash subsidy, one for the labor market, and other for the public finance. This section will briefly tackle these issues and indicate that they do not constitute sound reasons against providing cash subsidies to family caregivers in Hong Kong.

The Report states that the provision of a cash subsidy to family caregivers may encourage people to become family caregivers and thereby withhold or withdraw from the labor market. Therefore, such provision, it is argued, would turn out to be a disincentive for people to join the workforce and thus would negatively affect the labor market. We think this worry is ungrounded. First, the subsidies should only be given to those caregivers who are from low-income families, not to any from middle- or upper-income families. Some may want to argue that such subsidies should extend to middle-income families to incentivize more individuals to stay at home and provide care for their elderly members. We do not think equity consideration supports such extension. Even if tax allowances are insufficient for the middle-income to provide home care, most of them are already capable of hiring domestic helpers to do the work at home. Providing support to low-income families is much more necessary and urgent.

Moreover, it is unlikely that many individuals from low-income families would prefer to become full-time family caregivers primarily for the sake of the money offered by such subsidies, since the money from such a subsidy would be lower than a salary one may obtain from the market. In addition, full-time, intensive caregiving for an elderly family member is a highly time-consuming and emotionally draining work. Such subsidies would only attract those individuals who are virtuously willing to take care of their elderly relatives at home for a minimal income support. Finally, providing cash subsidies to low-income family caregivers would not significantly affect the job market because ever-increasing automatization and the use of robots in the workplace have begun to replace more and more low-skill workers. Unemployment would inevitably grow when individuals cannot migrate from low-skill work to mid-skill or high-skill work. Although the government should offer unemployment aid, new training and reskilling programmes for such individuals, providing them the opportunity to become family caregivers through subsidies would also be a valuable way to assist them while improving the elderly care of the society.5

The Report fears that providing cash subsidies would incur financial and manpower costs, which ultimately would increase the financial burden of public services. We think this depends on how subsidy provisions are designed and monitored. First, a means-test mechanism must be enforced. As a necessary condition for becoming a family caregiver to receive a subsidy, a qualified person must be from a low-income family. Moreover, the amount of such subsidy should not be more than the amount of the welfare fund (namely CSSA in Hong Kong) that an older adult has received or is going to apply for institutional elderly care. In the financial year 2017–2018, the government spent as much as HK$257.6 million in CSSA for elderly people to pay for their institutional care (Hong Kong Government 2019). Such huge amount of payment in CSSA can be significantly reduced if cash subsidies to family caregivers are adopted. They will be saved and used instead for family care, without increasing total governmental budget. Accordingly, in the long run, the provision of such cash subsidy will not be a significant drain on public resources, as the demand for residential care services funded directly or indirectly by the government will not be significantly increased since more elders will live with their families and be cared for by family caregivers. Furthermore, regarding concern about the bureaucracy and manpower that would be required to monitor the wellbeing of the elderly at home, although we cannot contend that no such costs would be incurred, we trust that they would not be uncontrollable. As the government has already managed and monitored the operation of CSSA payment for elderly care in the current system, available civil servants from welfare departments and social workers could also serve to manage and monitor family caregivers for the care of the elderly at home. At the end of the day, even if the society would have to increase a bit more management costs than now by ensuring the accountability of the means-test administration and the monitoring of care quality in operating such subsidies family care, it remains worth doing because it can help meet elderly preferences, avoid unnecessary or premature institutionalization, and fulfil the governmental principle of “ageing in place.”

If anyone charges us for showing little understanding of and concern with the burden, risk, and plight of the family caregivers, most of whom come from a low-income background in Hong Kong, that would be a misunderstanding. We certainly advocate that more assistance be offered to support family caregivers in Hong Kong, including setting up governmental programmes designed for their education and skills training, environmental modification, care management, counselling, and respite care as offered in many other societies, although we do not have space to address them in this essay. But these measures by no means contradict our suggestion that monetary subsidies be offered to them in the first place. The reality is that many of them are already offering care for their elderly family members while living in financial difficulty but receiving no subsidy at all. That is why many have to apply for a special welfare fund (such as CSSA for institutional care) to send their elders to an institution against their preferences.

Would a subsidy as proposed lead to an exploitation of the poor but an unjust benefit to the rich? Some might be concerned that under such subsidies, the poor would have to care for their elders at home, being paid below market rate for the work, while it takes away the opportunity to compete for more well-paying positions that may alleviate poverty. At the same time, the objectors would add, the well-off hire domestic helpers to take care of the elderly in their home, not being burdened with caring for their elders, and continue to have the opportunity to be economically active. We think this is also a misunderstanding. First, no matter whether such a subsidy is offered to the poor, the rich remains living the way as they do. Thus, it is nonsensical to believe that providing such a subsidy would unjustly benefit the rich. Moreover, we recommend that the government continue to offer CSSA for institutional care. This means low-income families can continue to apply for it if they so wish. Thus, the proposed subsidy provides an additional option to gain funding for those who wish to take care of their elders at home. To offer such an additional option to the poor cannot constitute an unjust exploitation of them, because they have freedom not to choose it. Indeed, by providing such a subsidy, no person from a low-income family would be forced upon the caring work presently done by institutions, because everyone would have as much freedom to go to the market to improve their economic situation as before.

VI

Hong Kong is an ageing society. Its elderly people (aged 65 and older) made up 19.1 percent of its 7.5 million population in 2020 (Census and Statistics Department 2022). The COVID-19 pandemic has given us a valuable opportunity to reflect on Hong Kong’s elderly care policies. To facilitate ageing in place, the government should provide some form of income support to the family caregivers who are unable to support themselves because of the demands of their caring roles. This paper argues that the provision of a cash subsidy to family caregivers to meet their living expenses is a morally justifiable policy option to pursue ageing in place, thus avoiding unnecessary or premature institutionalization of the elderly when most of them prefer to live in their own home. We should learn from Western experiences in offering such a subsidy.

We rebut the social and moralistic reasons for not introducing cash subsidy to family caregivers. Confucianism upholds an adult child’s moral obligation to take care of their elderly parents, and this obligation includes giving necessary assistance to their parents in order to realize their wish for ageing in place. To provide cash subsidy to family caregivers does not monetize or tarnish this moral obligation. Instead, it can enable adult children from low-income families to take care of their older family members at home if they so wish. Of course, we do not mean to suggest that no other social or communitarian services be needed at the same time for improving elderly care in Hong Kong. Neither have we explored detailed policy measures regarding which relatives are qualified to be family caregivers, how much a subsidy should be offered, and how it should be offered. These will require additional research.

Declarations

The authors declared that the paper did not involve the use of animal or human subjects.