Sending people to care homes in lower ‐ income countries: A qualified defence

In recent years, a proportion of older Germans has been sent to relatively high ‐ end care homes within lower ‐ income countries where the care tends to be cheaper and more extensive than that in German care homes. Destination countries are found predominantly within Eastern Europe (e.g. Poland, Hungary, Czech Republic), but to a lesser extent also within South ‐ East Asia (e.g. Thailand). At the same time, these expatriations have caused much controversy, with some German commentators calling them ‘ inhumane ’ and ‘ shameful ’ . In this article, I argue that such criticisms are overdrawn. Although sending an older individual to a care home within a lower ‐ income country can be morally impermissible , I find that there are at least three sets of conditions under which it is not.

are being deported [abgeschoben] to care homes abroad'. 7Criticisms have also been levelled by a commentator in the Süddeutsche Zeitung, who wrote that 'Germany should be ashamed of itself' for sending its older inhabitants abroad, 8 as well as by the president of the German socio-political advisory group VdK, who said that 'we simply cannot let those people who built Germany up to be what it is, who put their backbones into it all their lives, be deported', and by the director of the German Alzheimer Society, who called these expatriations 'inhumane' [Menschenverachtend]. 9 According to a representative survey by TNS Emnida, a German polling institute, such opposition is widespread among the German population, with 85 percent of Germans reporting to be opposed to placing a relative in need of care within a foreign care home 'under all circumstances' as opposed to a mere 23 percent who reports being categorically opposed to placing such a relative within a domestic care home. 10e aim of this article is to show that such blanket opposition cannot be vindicated.As I will argue, there are at least three sets of conditions under which it is morally permissible to send people to care homes within lower-income countries.Before looking at these, a few preliminary comments are in order.
The first is that my focus in this article will be on cases where the would-be emigrants have lost the mental and communicative capacities to decide about moving to a care home within a lowerincome country and to make these decisions known, which will usually be due to the fact that they suffer from severe dementia.I will not try to settle here exactly when these capacities are lost.
Suffice it to say that when people can longer independently communicate whether they would want to live in a (particular) foreign care home, it should not be readily assumed that they are unable to make their preferences known (insofar as they have any) given that they might still be able to do so if others assist them. 11at said, even if with such assistance, it will often be the case that severely cognitively impaired individuals can no longer express any preferences on this subject, which will in many cases be due to the fact that they can no longer ponder a move abroad.In such cases, and this brings me to my second preliminary comment, other parties will need to decide about sending them to a care home within a lower-income country.Such parties might include a spouse, child, state-appointed guardian, or anyone whom the would-be emigrants have nominated as their welfare attorney before they became severely cognitive impaired. 12e rest of this article is structured as follows.Section 2 identifies a condition that always needs to be satisfied in order for it to be morally permissible to send severely cognitively impaired individuals to care homes within lower-income countries.This condition states that, insofar as such expatriations harm vulnerable members of the host populations, these individuals should not suffer significantly greater harm than they would suffer if this type of migration does not take place.Section 3 then identifies the remaining conditions of each of the three sets under which people with severely cognitive impairments are permissibly sent to care homes within lower-income countries.According to the remaining conditions of the first set, sending a severely cognitively impaired person P to a care home within a lower-income country is necessary for P to enjoy a minimally decent life, or simply one that is significantly closer to this threshold.According to the remaining conditions of the second set, sending P to such a care home honours P's autonomy, and does not deprive P of a minimally decent living standard or of a living standard that is broadly as close to being minimally decent as P is able to enjoy within her current society.And according to the remaining conditions of the third set, P has at least some informal care-givers C who are providing P with morally supererogatory care and who want to send P to a specific care home within a lower-income country, whereby it must be the case that, without C's supererogatory care, P is unlikely to enjoy a minimally decent life within her current society, while being likely to enjoy a significantly higher quality of life in the relevant foreign care home.Section 4 concludes.

| IMPACT ON HOST POPULATIONS
Let us start then by looking at a condition that I believe ought to be invariably satisfied in order for it to be morally permissible to send severely cognitively impaired relatives to care homes within lowerincome countries.According to this condition, which I will refer to as the 'no-greater-harm-to-host-populations condition', Insofar as such expatriations harm vulnerable members of the host populations, this group should not suffer significantly greater harm than they would suffer if these expatriations do not take place.
One way in which such harm might be caused is that the expatriated occupy scarce places in care homes that would otherwise have been occupied by locals.Even if locals are not formally barred from living in these homes, an influx of relatively wealthy foreigners might make them unaffordable to them by raising rental prices.
Another way in which locals may be harmed is that this type of migration engenders or reinforces domestic care drains and medical 7 Bild.(2012, December 11).Schon Über 10 000 Deutsche Rentner Leben in Osteuropa.
Bild.de.https://www.bild.de/ratgeber/2012/altenheim/schon-ueber-10000-deutscherentner-leben-in-osteuropa-27145824.bild.htmlbrain drains.This happens when local care-workers and local medical specialists start offering their services to comparatively wealthy foreign clients rather than members of the local population in order to make more money, 13 which is a phenomenon that has been witnessed in the related context of medical tourism. 14ile these effects are clearly problematic, it might be asked whether they are more problematic than the effects of not sending people from higher-income countries to care homes within lowerincome countries given that as, as we will see in Section 3.1, this may prevent these individuals from receiving adequate care or care that is significantly closer to being adequate.The reason why I think that this is indeed the case is that inhabitants of lower-income countries generally live less privileged lives than inhabitants of higher-income countries, ones in which they tend to face greater struggles to satisfy their basic needs. 15What this means is that when comparatively wealthy foreigners consume aged care-and health care-resources that inhabitants of lower-income countries would have consumed otherwise, those who are worse off than themselves are rendered even worse off.There are two influential types of moral theories that offer an explanation as to why this is objectionable.The first type maintains that, ceteris paribus, allocating a fixed unit of resources to those with relatively few resources is more important than allocating it to their more resourceful counterparts on the ground that they will derive greater value from it, assuming diminishing marginal utility.
Theories that accept this principle are known as 'prioritarian theories'.
The second type maintains that what matters first and foremost, if not exclusively, is that people be able to live minimally decent lives.
Since inhabitants of lower-income countries are less likely to live such lives than inhabitants of higher-income countries, theories of this type, which are known as 'sufficientarian theories', prescribe similarly that, all other things being equal, the former's interests ought to be prioritized. 16at is important for us is that, even if I am right that it is not only morally problematic for expatriations of severely cognitively impaired individuals to care homes within lower-income countries to undermine the aged care-and health care-access of vulnerable local inhabitants, but more problematic than letting the former endure hardship that could be avoided by sending them abroad, it does not follow that such expatriations will always be unjustified.One reason for this is that there are ways in which the aged care-and health careaccess of vulnerable local inhabitants might be protected from the abovementioned ills.To begin with, insofar as the number of people who move into care homes within lower-income countries is going to rise in the coming years and decades-as is probable given that the populations of many higher-income countries are ageing fast 17states may start to implement measures that prevent and/or off-set these effects, which would be akin to the ones that some have implemented to address the harmful consequences of international brain drains within the medical sector. 18For example, sending states might start to construct care homes within the host societies so that the number of care home places for local residents is not being reduced, whereas receiving states might begin to impose a special tax on care homes with relatively wealthy foreign clienteles and spend the revenue generated by this tax on building affordable care homes across the country and/or on subsidizing the medical training of those who commit to working in the public health care sector for an x-number of years.But even when such protective policies are not forthcoming, there are things that inhabitants of higher-income countries can do to avoid undermining the aged-care and health careaccess of vulnerable local inhabitants.For example, they might specify in an advance directive that if their relatives ever deem it fit to expatriate them to a care home within a lower-income country, they should send them to one where their admission is likely to benefit locals, such as a care home that is risking closure due to declining resident numbers.Another option would be for them to enshrine a wish in such a directive that (part of) the money that they save by living in a care home within a lower-income country be awarded to local health care organizations.And even when people have never communicated such wishes before they became severely cognitively impaired, those who are legally authorized to manage their finances might still take protective measures like the ones just mentioned on their behalf. 19at if any macro-and/or micro-level measures that are taken fail to (completely) protect the aged care-and health care-access of vulnerable local inhabitants?In that case, I still do not think that sending severely cognitively impaired individuals to care homes within lower-income countries must be morally unjustified given that the harm that such expatriations might cause to this group need not be greater than the harm that they would suffer if the relevant expatriations do not occur.To see this, it should be noted that when fewer (comparatively wealthy) inhabitants of higher-income countries move into care homes within lower-income countries, more local aged care-workers and medical specialists can be expected to migrate to higher-income countries in order to earn higher wages abroad, which is already a widespread phenomenon. 20When such care drains and medical brain drains occur, not only is the aged care-and health 13 Bally-Zenger et al., op. cit. note 4, p. 144. 14 Turner, L. (2007).'First world health care at third world prices': Globalization, bioethics and medical tourism.BioSocieties, 2(3), 303-325.https://doi.org/10.1017/S1745855207005765 15Basic needs including those to for example adequate food, shelter, safety, and health care. 16Notice that for members of higher-income countries to harm vulnerable members of lower-income countries is more problematic still when the former countries are at least in part responsible for the fact that the latter countries are poorer.This may be the case, for instance, when they recognize corrupt, exploitative governments of lower-income countries as legitimate trading partners; when they allow these governments to borrow money in their country's name; and when they help to sustain an international trading system (the WTO regime) that some have argued is unfairly skewed against the interests of lower-income care-access of vulnerable inhabitants of lower-income countries affected as well, any friends or relatives of theirs who migrate in order to provide aged care and/or health care abroad will no longer be living within their society, which is a significant social cost. 21

| JUSTIFIABLE EXPATRIATIONS
To reiterate, my contention in this article is that there exist at least three different sets of conditions under which sending severely cognitively impaired individuals to care homes within lower-income countries is morally permissible.In the previous section, I have identified a condition that must always be satisfied, and that consequently features in each of the three sets.This condition states that, insofar as such expatriations harm vulnerable members of the host societies, this group should not suffer significantly greater harm than they would if the relevant expatriations do not take place.My aim here is to consider what further conditions need to be satisfied in order to complete the relevant sets.

| Minimally decent lives
The first set that I want to look at requires one additional condition to be satisfied.According to this condition, sending a severely cognitively impaired person to a care home within a lower-income country is necessary for her to enjoy a minimally decent life (by which I mean a life in which all of a person's basic needs are met, including our interests in adequate safety, shelter, food, health care, and non-cruel companionship), or simply one that is significantly closer to this threshold even when it still falls short of it.Helping people to live minimally decent lives, or ones that approximate the decencythreshold as closely as possible, is important not only because it promotes their well-being (understood as the presence of happiness and the absence of pain and suffering), although this clearly carries a lot of moral weight.It is also necessary in order to respect their dignity, which is widely understood to matter independently of how it affects their well-being (which explains, for instance, why many believe that it is objectionable to leave a woman with severe dementia topless in her room even if she is not bothered by this because of the high temperature and because she is no longer aware of the prevailing dress codes within her society).
What is important for our purposes is that there are cases where the current condition seems to be satisfied.To bring this out, notice that, within various higher-income countries, a large share of older people is currently unable to live minimally decent lives.For example, a cross-national study from 2012 showed that nurse staffing standards and staffing levels were lower than experts recommended within the United States, Canada, Germany, and England. 22More recently, a report by health economist Heinz Rothgang found that, on average, residents of German nursing homes receive 99 min of care per day, which falls well short of the daily average of 141 min that they are thought to require in order to enjoy an adequate living standard, 23 and which is a figure that is unlikely to improve significantly anytime soon even when additional public investments are made as German society continues to age 24 and as a shortage of roughly half a million careworkers is expected by 2030. 25Further evidence that many care homes within higher-income countries are struggling to provide adequate care is offered by reports of staff-on-resident abuse.For example, a British survey among 1,544 care home-workers found that such abuse had taken place in 91 out of 92 surveyed homes within the past 3 months, 26 whereas 10%-11% of care-dependent older people in Germany is estimated to become the victims of abuse. 27 the same time, there exists evidence that the care that some Germans are receiving in relatively high-end care homes within lower-income countries is better than the care that is available to them in a large proportion of German care homes, which is due mostly to differences in staff-to-resident ratios.For example, fieldwork by Jill Brütsch, who in 2015 spent 2.5 weeks in Thailand visiting two care homes for German residents with dementia, showed that, in both homes, residents had at least one care-worker to themselves at all times. 28Even after taking into account that Thai care home staff do not tend to be as highly trained as their German counterparts,29 or at least not formally, the significant shortcomings of the residential care within Germany (see the previous paragraph) make it reasonable to suspect that, for some Germans, the downside of being looked after by (formally) less qualified staff is outweighed by the substantially more extensive care that they are able to receive within these foreign care homes.Or consider the care home, 'At the Riverside' in the Polish town of Zabelków, which has 59 German residents and reportedly five to six care-workers for every residentby comparison, the staff-to-resident ratio for individuals with moderate care needs in Germany is 1 to 13 according to Alzheimer Europe 30 -who are said to be at least as well trained as care home staff within Germany, if not better trained as the professional training 21  for nurses in Poland lasts 2 years longer than its German equivalent. 31In a video report by the Rheinische Post, a German daily, several German residents and their relatives speak highly of how the Polish care home is being run.For instance, August Schmidt, 82, says that the staff are treating him and his fellow residents 'like their own children', while Horsch Laschet, whose brother lives in the care home, notes that the 'care is done with more love [Liebevoller]' in a way that is 'unimaginable within Germany'. 32w, some might argue that whether older people are able to live a minimally decent life is not solely determined by the care to which they have access, but also by whether they feel comfortable within their cultural-linguistic environment and social environment.To the extent that this is correct-as I assume here it is-this means that, even when they can receive superior care in a foreign care home, their chances of attaining an adequate living standard might still be higher within a domestic care home insofar as living abroad would expose them to (disutility-inducing) cultural-linguistic differences and/or social differences (most notably reduced contact with relatives and friends) that are absent, or simply not as strong, within domestic care homes.
There are two things to be said in response.The first is that, since I am focusing upon severely cognitively impaired persons, any linguistic, cultural, and/or social differences that are manifested within foreign care homes might not be noticed by this group, or only to a small extent, as a result of their cognitive impairments. 33With respect to linguistic differences specifically, it has been suggested when individuals with advanced dementia have largely lost the ability to understand and use verbal language, the fact that they might not share a verbal language with their care-givers will matter little as nonverbal communication will be much more important in such cases. 34e second thing to say is that, even when potential linguistic, cultural, and/or social differences are noticed by (some) severely cognitively impaired emigrants, and done so to a meaningful degree, it remains doubtful whether any reductions in well-being that this might cause will invariably outweigh the increases in well-being that they may experience as a result of receiving superior care.In fact, when we recall the considerable shortcomings of the residential care within various higher-income countries, along with the substantially more extensive care that their inhabitants can receive in certain care homes within lower-income countries, one would expect that, in terms of well-being, living in these foreign care homes will often still be a net improvement for severely cognitively impaired inhabitants of higher-income countries.
At this point, a critic might maintain that, even when sending severely cognitively impaired individuals to care homes within lowerincome countries is necessary for them to enjoy a minimally decent life, or simply one that is significantly closer to this threshold, and even when this is possible without violating the no-greater-harm-tohost-populations condition (see Section 2), it still does not follow that expatriating them must be morally permissible.The reason it does not, she might say, is that such expatriations might still undermine the would-be emigrants' autonomy understood as the extent to which they live more or less successfully in accordance with an independently endorsed conception of the good life, that is a conception of what makes their life worth living that they have endorsed free from manipulation and brainwashing. 35me may reply here that when people have lost the cognitive ability to decide about moving to a foreign care home, they will have lost the ability to live autonomously given that they will no longer be able to reflect upon what makes their life worth living.Insofar as this is correct, it must be impossible for their autonomy to be undermined by an expatriation.
The problem with this response is that personal autonomy is widely, and I assume here correctly, understood to be a property of someone's entire life. 36What it requires is that a person's life on the whole be more or less congruent with her conception of the good life.
Whereas such a conception needs to be independently endorsed at some stage, which is when the relevant person must have the mental capacity to reflect upon what makes her life worth living, for her to live autonomously does not require that she retain this capacity throughout her life.However, if this is correct, then insofar as people with severe cognitive impairments used to have wishes not to be sent to a foreign care home, or simply not to one within a lower-income country, sending them to a care home within a lower-income country will undermine their autonomy.In fact, some philosophers would go further by arguing that, even when severely cognitively impaired individuals have never pondered such a move, sending them abroad will harm their autonomy nonetheless when they would have had antiexpatriation wishes had they pondered it when they were still capable of this.
Although a lot more could be said about this topic, what is important for us is that such (counterfactual) past preferences against being expatriated are not always present.For one thing, it seems that cosmopolitan-minded individuals often will not mind being sent to a care home within a lower-income country if, at some point in the future, they (a) become severely cognitively impaired and (b) come to enjoy much better prospects of living a minimally decent life within such a foreign care home, at least as long as (c) their loved ones continue to visit them from time to time (the desired frequency of which will vary across persons).For example, one German resident of 32 Wyglenda, B. (2016, June 29)."Oma-Export": Zur Pflege nach Polen.RP ONLINE.https:// rp-online.de/leben/gesundheit/news/pflegeheim-in-polen-fuer-deutsche-der-check_aid-18301523.For praise for other foreign care homes with predominantly German and Swiss clienteles, see the testimonies in Schwiter et al.,op. cit. note 3,op. cit. note 3,p. 116;Bender & Schweppe,op. cit the care home in Zabelków reports being 'indifferent as to whether one is being looked after by a German or Polish care-giver-the main thing is that one is looked after properly'.37 For another, we will see in the next subsection that there are cases where sending people to care homes within lower-income countries does not simply not undermine their autonomy, but actually honours it. Ths may be true, for instance, when a severely cognitively impaired immigrant had a longheld wish to spend her final years within her country of origin.
What about cases where sending severely cognitively impaired individuals to care homes within lower-income countries does undermine their autonomy?Even in such cases, I believe that it is dubious whether their surrogate decision-makers can have moral duties to refrain from sending them abroad when doing so would allow them to enjoy a minimally decent life, or simply one that is significantly closer to this threshold, assuming once more that this does not violate the no-greater-harm-to-host-populations condition (see Section 2).Perhaps the easiest way of showing this is to point out that such duties would require their surrogate decision-makers to let them suffer indignities and hardship-think, for instance, of deprivations of regular showers and baths, and possibly even of regular abuse by overwhelmed care home-staff 38 -that could be (largely) avoided if they were to send them to care homes within lowerincome countries.The problem with this is that it seems unduly demanding to expect people to allow those whose well-being they have a unique responsibility to protect to suffer such gratuitous indignities and hardship, 39 which can cause severe feelings of guilt.
Before moving on, some might question the sufficiency of the identified conditions by arguing that when severely cognitively impaired individuals are sent to care homes within lower-income countries, this will disincentivize higher-income countries from investing in domestic aged care. 40The reason why this may be deemed undesirable is that it might ultimately result in more people being sent abroad who would have preferred to have spent their final years within their current society, as well as in more relatives and friends being forced to live far apart.
My response is that, while any such consequences are pro tanto problematic, they do not seem to provide decisive reasons against expatriating people under the current conditions (or, for that matter, against doing so under the conditions of the remaining two sets, which are discussed in the subsequent subsections).To vindicate this claim, a couple of observations are in order.First, as the already high costs of aged care within many higher-income countries continue to grow due to population ageing, for these states to be able to invest less money in aged care thanks to this type of migration need not be a bad thing if the money saved is invested instead in other important societal goods (e.g.education, the economy), or simply left to tax-payers to spend as they see fit.
Second, since aged care within higher-income countries is often provided by care-workers from lower-income countries (see the previous section), not sending older people to care homes within lower-income countries will in many cases contribute to more people from these countries moving to higher-income countries to provide aged care, which has social costs that are at least as serious.Third, and most importantly, for any single individual not to be sent to a foreign care home is bound to have a negligible effect on a government's willingness to invest in domestic aged care.The reason this matters is that it means that when we are legally and morally responsible for the welfare of a particular older adult (e.g. a relative), we would abdicate our fiduciary responsibilities by not sending her to a foreign care home when this would serve her interests considerably simply because of the miniscule disincentive that this would create against public investments in domestic aged care (assuming for a moment that such disincentives are indeed problematic all-things-considered, which I have just suggested need not be the case within societies with severe [expected] care-worker shortages).

| Autonomy
Having discussed the first set of conditions under which sending severely cognitively impaired individuals to care homes within lowerincome countries appears to be justifiable, I now want to turn to the second set.The conditions of this set obtain when such expatriations 1. help to honour the emigrants' autonomy; and do so 2. without depriving them of the opportunity to live minimally decent lives, or lives that are broadly as close to being minimally decent as the ones that are available to them within the sending societies; and 3. without causing significantly greater harm to vulnerable members of the host societies (insofar as any harm is caused to this group at all) than these individuals would suffer if such expatriations do not take place.
A case where condition (1) is satisfied has been mentioned already when I noted that, before some immigrants became severely cognitively impaired, they may have had a wish to spend the final years of their life within their country of origin.For example, a Turkish person who migrated to the Netherlands during the 1970s as a guest worker may have wanted to return to Turkey and live in a local care home.Other cases where condition (1) might be satisfied include ones where severely cognitively impaired individuals used to have a wish to spend their final years within a country with a warm and sunny (e.g.Mediterranean) climate, perhaps because they suffer from arthritis of which the symptoms tend to be less painful within warmer climates, and ones where they used to have a wish not to receive informal care from their children, which may be necessary if they were to live in a domestic care home because of staff shortages, but not if they moved into a relatively high-end care home within a lower-income country (see Section 3.1).Since personal autonomy is an important element of a well-lived life, and respect for people's autonomous choices an important good, 41 it should be clear that, when a person's autonomy is honoured by being sent to a care home within a lower-income country, this will be a strong pro tanto reason for expatriating her.Still, that does not mean that these reasons are always strong enough to render such expatriations morally justified.In Section 2, I have argued already that they are not strong enough when this type of migration causes significantly greater harm to vulnerable members of the host populations than these individuals would suffer otherwise, hence condition (3).In addition to this, and this brings us to condition (2), it looks like people's interests in living minimally decent lives, which it was noted are both well-being-related and dignity-related (see Section 3.1), are so fundamental that when sending severely cognitively impaired individuals to care homes within lower-income countries prevents them from living such lives, or from living ones that are broadly as close to the decency-threshold as those that are available to them within their current society, their interests in remaining within their current society will trump any autonomy-interests that they might have in being expatriated.Whereas a defence of this claim is beyond this article's scope, I want to make two comments on it.The first is that rejecting it would seem to treat personal autonomy as a master value, that is as a value that invariably trumps all others, which is something that few philosophers are prepared to do as it is widely understood to trivialize other morally important goods, including the absence of pain and suffering. 42e second comment is that, even if the current claim does prove to be untenable, this does not affect my broader thesis that sending severely cognitively impaired individuals to care homes within lower-income countries is sometimes morally permissible.On the contrary, without condition (2), the conditions of the current set become easier to satisfy.

| Unwanted supererogatory caregiving
Which brings us to the third set of conditions under which it seems to be morally justified to send severely cognitively impaired individuals to care homes within lower-income countries.The conditions of this set centre around the interests of any informal caregivers that the would-be emigrants might have, who will usually consist of friends and/or relatives.They obtain when: 1.A severely cognitively impaired person P has at least some informal care-givers C who are providing P with morally supererogatory care, and who want to send P to a specific care home within a lower-income country.
2. Without C's supererogatory care, P is unlikely to enjoy a minimally decent life within her current society, while being likely to enjoy a significantly higher quality of life in the relevant foreign care home.
3. Sending P to this care home does not cause significantly greater harm to vulnerable members of the host population than these individuals would suffer if P's expatriation does not take place (insofar as any harm is caused to them at all).
The easiest way of vindicating these conditions is to start by recalling my defence of the first set of conditions in Section 3.1.
There, I argued that when sending a severely cognitively impaired person to a care home within a lower-income country is necessary in order for her to enjoy a minimally decent life, or simply one that is significantly closer to this threshold, and does not cause significantly greater harm to vulnerable members of the host population than these individuals would suffer if such expatriations do not take place (insofar as any harm is caused to them at all), expatriating the person will be morally permissible because of our fundamental well-beingand dignity-related interests in living minimally decent lives.However, if this is correct, then insofar as these conditions would obtain if a given informal care-giver, or number of informal care-givers, C stopped providing morally supererogatory care to a severely cognitively impaired person P (which, means, inter alia, that P is unable to enjoy an adequate living standard in a domestic care home), for C to want to send P to a care home within a lower-income country that satisfies condition (2) would seem enough to render an expatriation justified.
In order to bring this out, consider first a scenario where C is legally authorized to expatriate P and decides to do so.Here, it looks like neither P nor anyone else can have a reasonable complaint against C for expatriating P. To see why, notice that, by definition, the supererogatory care that C was providing to P was one that C was not morally required to provide and, without it, a set of conditions (those of set 1) would obtain under which an expatriation was found to be morally permissible.However, if it is morally permissible for C to stop providing supererogatory care to P and subsequently expatriate P, then it seems that it must also be morally permissible for C to expatriate P directly given that this would spare P the hardship of living within her current society without C's supererogatory care (which, under the current conditions, is significantly greater than any hardship that P might suffer in the foreign care home to which C wishes to send her).
What if the legal authority to expatriate P rests with another individual D? In that case, I take it that it remains morally permissible to expatriate P, if not morally necessary (I leave this for the reader to decide).The reason for this lies in the fact that, under the stipulated conditions, for D to defy C's wish for P to be sent to a care home within a lower-income country would put considerable pressure upon C to continue providing supererogatory care to P given that, without this care, P's chances of living a minimally decent life would be significantly reduced and end up being significantly worse than if P were sent to a (specific) care home within a lower-income country.Since it 41 See for example, Colburn, op.cit.note 35; Dworkin, R. (1994) is true by definition that the provision of supererogatory care is not something that can be reasonably expected of C, for D to let C be exposed to this pressure against C's will would show little regard for C's autonomy and well-being and be highly problematic on those grounds.

| CONCLUDING REMARKS
While blanket opposition to the practice of sending people to care homes within lower-income countries is widespread among the German population, this article has argued that such opposition cannot be vindicated.To be more precise, it has argued that there are at least three sets of conditions under which individuals with severe cognitive impairments are permissibly expatriated to these facilities.I want to end with a few comments.The first is that more could be said about exactly when the conditions of each set are satisfied than I have been able to do within the available space, which is an important task for future research.The second comment is that, as the phrase 'at least three sets' indicates, I have not tried to offer an exhaustive list of sets of conditions under which it is morally permissible to send severely cognitively impaired individuals to care homes within lower-income countries.An investigation into whether more such sets exist is an important task for future research as well.