Clinical labor

Tissue donors and research subjects in the global bioeconomy

Melinda Cooper and Catherine Waldby

— Reviewed by Neil Singh

14 Apr 2016

Melinda Cooper and Catherine Waldby, Clinical Labor: Tissue Donors and Research Subjects in the Global Bioeconomy. Durham, NC: Duke University Press, 2014. 296 pp., $24.95 ISBN: 9780822356226.

It occurred to me, while working in a stem cell laboratory several years ago, that biomedicine seemed to have things the wrong way round. Of all the people involved in our research, there was only one person who was indispensable: the patient who had donated the initial clump of cells that had just the right characteristics to be useful. Everyone else was, to a greater or lesser degree, replaceable – just a technician doing his or her bit. And yet, the tissue donor was the only person in the process who was not paid for their contribution, nor were they formally acknowledged on the papers that came out of the research.

In their excellent book, Melinda Cooper and Catherine Waldby invert biomedicine, putting things in their rightful order, with tissue donors and research subjects finally taking their place as players whose contribution and voice must be acknowledged. The book begins with a deceptively simple question that underpins the analysis: What is labour? The sophisticated argument that follows asserts that both reproductive work and clinical trial work elude canonical notions of industrial labour as espoused by human capital theory (which assumes the suspension of power relations between contractor and contractee), because power asymmetries are unavoidable when ‘the labor involved is entirely concerned with the living processes that sustain the contracting self’ (p. 228).

The analysis hinges on the distinction between Fordist economies (workers in permanent, full-time positions in industries that mass manufacture goods for sale, who are protected by work-based social insurance) and post-Fordist economies (outsourced contractors in temporary posts in a deregulated and globalised service economy, who insure themselves). What triggered this shift from a Fordist manufacturing economy to a post-Fordist service economy? The authors suggest that the driver of this change was the entry of women into the paid workforce in the United States in the 1960s, which blurred what was previously a more clearly delineated distinction between the private (feminine, reproductive, unpaid) and public (masculine, productive, paid) spheres.

This transformation of intimate bodily functions – domestic work, sexual work, care provision – into exchangeable commodities matched a shift in economic thought, as described in chapter 2. At first glance, it might seem progressive to include these previously unpaid private duties in the economy. After all, for decades feminists had been asking for care work to be seen as a form of labour and not an altruistic service or an essence of femininity. Putting these roles into the realm of circulation seems like a just way to remunerate caregivers for their time and energies.

However, in reality this move – which meant ‘reconstituting the domestic sphere of the Fordist household as a reserve of contractual services’ (p. 29) – was driven not by a progressive urge to encourage the breakdown of traditional Fordist family and social divisions, but rather as a libertarian response to this breakdown. The Chicago School of economics’ human capital theory led not to the liberation of women and people of colour from the discrimination that had for centuries underpinned their oppression and exploitation, but instead to a remodelling of the economy in order to adapt to the civil rights movement, so as to reassert the dominance of global finance and imagine new ways of generating surplus value. The overarching assumptions of capitalism were not challenged but in fact reinforced by the Chicago School’s economic theory, and the result was a swathe of influential policy changes that amounted to ‘the privatization of labor and the contractualization of reproduction’ (p. 28).

Chicago School thinkers, from Frank Knight in the 1920s to Gary Becker in the 1970s, saw the source of value not as labour but as capital itself. In this worldview, power relations are ignored. The economy is split, not into employers and employees, but rather into individuals; each an economic agent meeting as equals according to the principle of volenti non fit injuria (‘no injury can be done to consenting parties’). By reintroducing labour into the equation, Cooper and Waldby’s superb materialist critique of the neoliberal bioeconomy reminds us that such a worldview is a myth. The rest of the book is an attempt to prove that ‘there exists a real and decisive difference between those who take immaterial monetary risks to generate profit … and those who bear the material, bodily risks of innovation in return for a wage’ (p. 31). But if such participation in the bioeconomy is neither altruistic service nor industrial labour, then how should we think of it? Their answer is ‘clinical labour’, defined as when ‘the abstract, temporal imperatives of accumulation are put to work at the level of the body’ (p. 12).

Part 2 of the book examines the trade of reproductive services in the global bioeconomy, which developed as a result of scientific and technological developments that have uncoupled reproduction from the female body. However, one part of reproduction cannot (as yet) be done ex vivo: gestation. The result is that ‘unlike the industrial worker, the gestational mother literally embodies the means of production’ (p. 60). Accordingly, the authors argue that industrial labour contracts cannot easily be applied to gestational surrogacy, since ‘the surrogate’s productivity cannot be readily framed as fungible, abstract labor’ (p. 60). And yet they are. In chapter 4, the authors discuss how the Chicago School’s resurrection of the ‘specific performance’ of contract (as a way of enforcing contractual obligations between contractor and contractee) has perverse consequences in this context. For instance: ‘the court enforces the family rights of the intending parents over the labor of the surrogate… . The surrogate’s labor does not belong to the surrogate herself; rather, it is part of the commissioning couple’s biological inheritance… . The surrogate must accept a money equivalent for the child’ (p. 60, emphasis in the original).

In Part 3, the authors examine how post-Nuremburg safeguards designed to protect vulnerable persons led to a dwindling of research subjects and thus triggered ‘the vertical disintegration of the prison-industrial-pharmaceutical complex’ (p. 120) in the West, forcing biomedicine to find new ways to experiment, and new populations to experiment on. Chapter 6 looks at the outsourcing of clinical trial work in the West from state-run total institutions to private clinics, alongside the growth of ‘managed care’ in the 1980s. But high costs and strict regulations ‘push[ed] the clinical trial process offshore’ (p. 158), and chapter 7 examines the effects of this on postsocialist China and postcolonial India. Cooper and Waldby persuasively argue that the work of the industrial labourer and the clinical trial participant are like chalk and cheese, since ‘unlike the industrial laborer, [the clinical trial subject] participates in a labor of ingestion and metabolic self-transformation rather than expending energy in transforming the physical object’ (p. 135).

The final two chapters briefly problematise outsourced clinical trials, intellectual property, and unregulated drug prices. The authors discuss a partial solution to these problematics: user-generated drug innovation, whereby scientists, clinicians, companies, and patients all co-produce drugs through participatory research. However, it would have been nice to hear more about exactly what forms of contribution would count as clinical labour. For instance, they state that ‘voluntarism and gift relations may be justifiable in some spheres (for example, blood and solid organ donation within national boundaries)’ (p. 224), and I was left unsure how to distinguish such altruistic bodily gifts from clinical labour.

The book is a crucial addition to the literature on biocapital, and is historically rich, theoretically rigorous, and driven by a strong moral and political impetus. Its materialist feminist analysis provides a strong case that patients – like the one who donated cells for the stem cell research conducted by my colleagues and myself – should be remunerated and given protections in return for their contribution. This runs counter to recent US case law, such as the landmark 2003 Greenberg case, which ruled that individuals do not own their tissue samples once donated to researchers. Following Sunder Rajan (2006), Cooper and Waldby reveal how inadequate our current bioethical frameworks – with their implicit contractual individualism derived from the Fordist era – are in dealing with a post-Fordist economy. If such exploitation is still possible and prevalent within bioethics’ compass, then whom does it serve, and what can we do to reclaim it?

About the author

Neil Singh is a medical doctor working in the UK National Health Service. He teaches at Brighton and Sussex Medical School.


Sunder Rajan, Kaushik. 2006. Biocapital: The Constitution of Postgenomic Life. Durham, NC: Duke University Press.