AMA Journal of Ethics^®

The notion that one is too good to do what is necessary for somebody to do is always weakening. The unwillingness, or the inability, to dirty one’s hands in one’s own service is a serious flaw of character. . .  [I]t can curtail or distort a society’s sense of the means, and of the importance of the means, of getting work done; it prolongs and ramifies the life and effect of pernicious abstractions.
Wendell Berry¹

The health care industry employs thousands of individuals at dismal wages. These workers are essential to health care and include patient care assistants, certified nursing assistants, home health aides, paramedics, custodial and security personnel, and environmental services workers, to name a few whose roles are often unrecognized in ethics and health policy investigations. Patient care assistants earn on average $17 000 to $27 000 per year,² while certified nursing assistants earn on average $22 000 to $31 000 per year, depending on the state in which they practice.3 Nationwide, the median wage of all health care support, direct care, and service workers was $13.48 per hour in 2019, while home health and personal care workers earned a median hourly wage of only $11.57.⁴ Despite working full-time or more, these workers rarely live on their wages alone. In 2019, nearly 20% of care workers lived in poverty, and more than 40% received public assistance.⁴ Women made up 81% of these workers, and an inequitable number were women of color.⁴ Their work is heavily relied upon by clinicians of status and by the systems in which they operate, but it is compensated meagerly, with unsustainably low pay and few benefits.

Moreover, demand for long-term care of elders and persons with disabilities is growing in the United States, as more people seek to age in place in their homes. The US Department of Labor predicts that demand for personal care aides will grow 33% between 2020 and 2030.5 Turnover among workers in these roles, which influences quality and continuity of care, was more than 60% in 2014.⁶

Yet we must take care to avoid focusing too narrowly on the economics of employment and these roles’ “essential” nature, which risks further commodifying the bodies and personhood of those performing this work. Many workers earning low wages, especially home health aides, patient care assistants, and certified nursing assistants, bring critical emotional knowledge to their jobs as caregivers. What’s at stake is more than typically supposed by supply-demand models, since US health care relies on these workers for daily, or even hour-to-hour, care of so many of our most vulnerable patients.⁷ Can clinicians of status care for patients in good faith without promoting good pay, benefits, and organizational support for workers delivering care that is valued at a small fraction of their own?

This issue of the AMA Journal of Ethics considers clinical and ethical dimensions of this question and investigates what we—as citizens, clinicians of status, and organizations—owe to these vulnerable workers. How should we better advocate for and build authentic solidarity with our colleagues? How should we improve the systems in which they work? How should we illuminate, amplify, and lift up their—and their roles’—importance? Preparatory to answering these questions, this issue investigates vast differences in power, education, compensation, and job security among workers on health care teams, as well as historical perspectives on policy that led to the low compensation for and invisibility of the labor of those earning low wages. The issue specifically considers wage theft, exploitative labor expectations, exclusionary pathways to professionalization, and patterns of marginalization among health care workers who earn low wages, despite their significant responsibilities. Finally, this issue offers examples of partnerships and solidarity from which all health professionals and students can learn.