Professional Documents
Culture Documents
Clinical Labor
Clinical Labor
Acknowledgments vii
Conclusion 221 Notes 229 References 243 Index 273
Acknowledgments
The idea for this book occurred to us more or less simultaneously at the Bio-
economies and Biovalue conference at Lancaster University in April 2006.
At that conference we first encountered the work of Kaushik Sunder Rajan,
who presented from his then forthcoming book Biocapital. For each of us,
this presentation crystallized a train of thought that was latent in our re-
spective work on markets, neoliberalism, and biomedical research. While
we had both contributed to the burgeoning critique of life sciences and con-
temporary capital in various ways, we had, like all the existing commentary,
focused on the uncanny hybridities of money, speculation, financialization,
and in vitro tissues. Listening to Kaushik’s presentation, we both realized
that we, and the rest of the field, had neglected the question of labor. While
there was an extensive body of work on the expert cognitive labor of the sci-
entist and its centrality to the knowledge economy, the labor of those who
provide the in vivo platforms for clinical experimentation and tissue provi-
sion did not figure in any account as labor. Or to be more precise, a burgeon-
ing literature did name these activities in passing as kinds of labor, but did
not probe what that might mean, how it might count, and what it might tell
us not only about the organization of the bioeconomy but about the broader
organization of labor and value today. So this became our task, and this book
is the result.
We have incurred many debts of gratitude to numerous colleagues, re-
ceived generous grant support, and presented work at a number of seminars,
conferences, and workshops. Catherine Waldby would like to thank Renee
Almaling, Warwick Anderson, Kathrin Braun, Nik Brown, Katherine Carroll,
Greg Clancey, Adele Clarke, Raewyn Connell, Gail Davies, Donna Dicken-
son, Maria Fanin, Peter Glasner, Herbert Gottweis, Erica Haimes, Elizabeth
Hill, Linda Hogle, Klaus Hoyer, Isabel Karpin, Julie Kent, Ian Kerridge, Char-
lotte Kroløkke, Rob Mitchell, Michel Nahman, Brett Neilson, Pat O’Malley,
Alan Petersen, Anne Pollock, Barbara Prainsack, Nikolas Rose, Brian Salter,
Loane Skene, Kaushik Sunder Rajan, Fredrik Svenaeus, Steve Wainwright,
Andrew Webster, and Clare Williams. For their essential personal support
and love she thanks her family, David, Valerie, Gavan, and Jenny, and her
partner, Paul Jones, who had to live with the inevitable psychic demands of
the writing process. While there are too many seminars to list, she would
like to particularly mention three that contributed strongly to the formation
of the book’s argument; the Symposium on Biocapital and Bioequity Insti-
tute for Advanced Studies / Worldwide Universities Network, University of
Bristol, 27 April 2011; The Body as Gift, Resource and Commodity workshop,
Södertörn University, Stockholm, Sweden, 5–6 May 2011; and the Clinical
Labour and the New Labour Studies seminar, University of Sydney, 21–22
May 2012. She thanks the participants in these workshops for their gener-
ous collegiality.
Melinda Cooper would like to thank Lisa Adkins, Fiona Allon, Warwick
Anderson, David Bray, Dick Bryan, Marina Cooper, Lucette Cysique, Jill
Fisher, Louise Freckleton, Mark Gawne, Elizabeth Hill, Martijn Konings,
Randy Martin, Angela Mitropoulos, Brett Neilson, Pat O’Malley, Anne Pol-
lock, Michael Rafferty, Brian Salter, Kane Race, Kaushik Sunder Rajan,
Miguel Vatter, Jeremy Walker, and Terry Woronov for their generosity in
time, conversation, and intellectual support. Several workshops and con-
ferences were crucial to the formation of the book’s argument. These in-
clude Experimental Systems, States and Speculations: Anthropology at the
Intersection of Life Science and Capital, University of California, Irvine,
13–15 April 2007; Life (Un)Ltd, organized by Rachel Lee at ucla Center for
the Study of Women, 9–12 May 2012; and the Clinical Labour and the New
Labour Studies seminar, mentioned above.
Catherine Waldby’s research was supported by two grants from the Aus-
tralia Research Council: Human Oocytes for Stem Cell Research: Dona-
tion and Regulation in Australia, lp0882054, and The Oocyte Economy:
The Changing Meanings of Human Eggs in Fertility, Assisted Reproduction
and Stem Cell Research, ft100100176. She also received support from an
Economic and Social Research Council International Visiting Research Fel-
lowship and from the Regenerative Medicine in Europe: Emerging Needs
and Challenges in a Global Context project, eu fp7 project. Melinda
Cooper’s research was supported by an Australian Research Council Grant
viii Acknowledgments
ft100100543, Experimental Workers of the World—the Labour of Human
Research Subjects in the Emerging Bioeconomies of China and India. Gen-
erous additional funds were provided from the International Office and the
Faculty of Arts and Social Sciences, Sydney University, and the Department
of Sociology and Social Policy provided a stellar research culture and colle-
gial environment for this work.
Some sections of chapter 5 are adapted from an earlier paper: Catherine
Waldby and Melinda Cooper (2010), “From Reproductive Work to Regen-
erative Labour: The Female Body and the Stem Cell Industries,” Feminist
Theory 11(1): 3–22. A modified section of chapter 4 appears in Catherine
Waldby (2012), “Reproductive Labour Arbitrage: Trading Fertility across
European Borders,” in The Body as Gift, Resource and Commodity: Exchanging
Organs, Tissues, and Cells in the 21st Century, ed. Fredrik Svenaeus and Martin
Gunnarson, pp. 267–295, Centre for Studies in Practical Knowledge, Söder-
törn University. Sections of chapter 6 dealing with the history of informed
consent and tort law appear in Melinda Cooper (2011), “Trial by Accident:
Tort Law, Industrial Risks and the History of Medical Experiment,” Journal
of Cultural Economy 4(1): 81–96. An abbreviated version of chapter 8 appears
in Melinda Cooper (2012), “The Pharmacology of Distributed Experiment:
User-Generated Drug Innovation,” Body and Society 18(3–4): 18–43.
Acknowledgments ix
Pa r t I
4 Chapter One
selves against the whole spectrum of life risks that were once taken in charge
(albeit partially) by the welfare state. Under these conditions, the wage itself
has become something of a speculative proposition—contingent, in many
cases, upon unspecified hours of unpaid work-readiness, conditional upon
the achievement of performance indicators, or fully integrated into the vo-
latilities of the stock market (as in the case of stock options as supplements
to traditional wages).
As the organizational form that emerged from the oil shocks and reces-
sions of the mid-1970s, post-Fordism presides over the breakdown of the
political and economic categories that structured the mid-twentieth-century
Keynesian era. In response to the return of middle-class women to the paid
labor force from the late 1960s, and the corresponding disintegration of the
breadwinner household with a full-time, unpaid housewife, post-Fordist
economies blur the boundaries between the reproductive and productive
spheres. Domestic tasks, sexual services, care provision, and, as we will see,
the process of biological reproduction itself have migrated out of the pri-
vate space of the family into the labor market and are now central to post-
industrial accumulation strategies. The New Household Economics devel-
oped by Chicago School economist Gary Becker represents one of the first
attempts to theorize this process within the limited framework of orthodox,
neoclassical economics: not incidentally, its exponents have been some of
the keenest champions of commercial markets in blood, organs, and repro-
ductive tissues, alongside other forms of human capital (Posner 1989; R. A.
Epstein 1995; Becker and Elias 2007). As both theorists of the New House-
hold Economics and their critics have observed, post-Fordist economies in-
ternalize the boundaries that the mid-twentieth-century social state placed
on commodification, pushing back at the limits between production and
social reproduction, production and consumption, production and circula-
tion, to turn even the most intimate of bodily functions into exchangeable
commodities and services (Becker 1981; Radin 1996).
A wide-ranging social science and humanities literature now recognizes
the multifarious ways that the biotechnical processes of “life itself” (Rose
2007) are involved in networks of commercial transaction and capital accu-
mulation. This literature has explored the speculative accumulation strate-
gies of the pharmaceutical and biomedical industries (Parry 2004; Thacker
2005; Sunder Rajan 2007; Brown et al. 2011); the logics of biocommodifica-
tion and commercial markets in tissues, organs, reproductive cells, organs,
and dna (Franklin and Lock 2003; Parry 2004; Waldby and Mitchell 2006;
6 Chapter One
vation—biofuels, synthetic biology, experimental cell therapies—and their
potential to propel the “advanced” economies out of economic recession.
Yet despite the conceptual inflation of the “bioeconomic” in contempo-
rary policy and theoretical discourse, few have explored the very material
ways in which the in vivo biology of human subjects is enrolled into the post-
Fordist labor process, through either the production of experimental data or
the transfer of tissues.1 We contend that such forms of in vivo labor are in-
creasingly central to the valorization process of the post-Fordist economy.
The pharmaceutical industry demands ever greater numbers of trial sub-
jects to meet its innovation imperatives, and the assisted reproductive mar-
ket continues to expand as more and more households seek fertility services
from third-party providers—gamete vendors and surrogates—and sectors
of the stem cell industries seek out reproductive tissues. The life science
industries rely on an extensive yet unacknowledged labor force whose ser-
vice consists in the visceral experience of experimental drug consumption,
hormonal transformation, more or less invasive biomedical procedures,
ejaculation, tissue extraction, and gestation. In the United States alone, the
epicenter of the global pharmaceutical industry, growing numbers of contin-
gent workers engage in high-risk Phase 1 clinical trial work in exchange for
money, while uninsured patients may take part in clinical trials in exchange
for medication that would otherwise be unaffordable. With the expansion of
assisted reproductive technologies, the sale of tissues such as eggs and sperm
or reproductive services such as gestational surrogacy has also emerged as a
flourishing labor market, one that is highly stratified along lines of class and
race. We refer to these forms of work as clinical labor.
The terminology is novel because, generally speaking, tissue donation
and research participation are not understood or analyzed as forms of work.
Rather, these forms of productivity are regulated through the conceptual
and institutional framework of bioethics,2 in which tissue providers—those
who surrender blood, semen, oocytes, embryos, kidneys, and other forms of
“live” tissue—are cast as altruistic donors who give for the public good, even
in cases where they are paid a fee or their tissues are commercialized (Tober
2001; Waldby and Mitchell 2006). Clinical trial participants are understood
to be volunteers who receive compensation rather than wages; nominally the
compensation rates, set by Institutional Review Boards (irbs) and Human
Research Ethics Committees, are kept low to discourage economic coercion,
but in practice the rates are often higher than minimum-wage rates for un-
skilled labor (Elliott 2008). The historical mission of bioethics, encoded in
8 Chapter One
“in kind” compensation for service, comparable to “workfare,” where the
payment of welfare benefits is made contingent upon the obligation to work.
Our research focuses on two of the largest, best-established, and transna-
tional markets in clinical labor—those represented by assisted reproductive
labor (including the sale of oocytes and sperm, and gestational surrogacy),
on the one hand, and the labor of human research subjects engaged in phar-
maceutical drug trials, on the other. By all estimates, these markets are vast.6
Clinical labor sustains some of the most patent-intensive sectors of the post-
industrial economy, yet most of this workforce intersects with the lowest
echelons of informal service labor, recruiting from the same classes mar-
ginalized by the transition from Fordist mass manufacture to post-Fordist
informatic production. Human research subjects and tissue vendors occupy
a liminal but critical position in the postindustrial biomedical economy. Un-
like the service workers who provide cleaning, catering, and other kinds of
low-level contract work for the knowledge economy (Sassen 2002), their
labor is fully internal to the value chains of the pharmaceutical and biomedi-
cal industries. The data generated by human research subjects is incorpo-
rated, in an immediate sense, into the investigational new drug application
that needs to be submitted to regulatory authorities before a drug is ap-
proved for marketing. Egg and sperm vendors and gestational surrogates
provide the living tissues and in vivo services that sustain a thriving economy
of public and private fertility medicine and stem cell research.
These forms of transaction, however, do not figure in economic analyses
of labor in the life sciences. Almost invariably, such investigations concern
themselves with the professional divisions of labor within the laboratory and
clinic and do not extend to the in vivo labor that sustains the innovation pro-
cess (Arora and Gambardella 1995; Nightingale 1998; Gambardella 2005).
This oversight is all the more significant given that the life science business
model is organized around a classical (Lockean) labor theory of value which iden-
tifies the cognitive labor of the scientist as the technical element necessary
to the establishment of intellectual property in living matter. The scientist’s
inventive step in isolating dna or creating a cell line from ex vivo tissues is
treated in innovation economics and patent law as the moment that creates
both property rights and appreciable commercial value from dumb biologi-
cal materials (Boyle 1996). In this account, the bodily contribution of tissue
providers and human research subjects appears as an already available biological
resource, as res nullius,7 matter in the public domain, even while in practice the
mobilization of these providers and subjects represents a growing logistical
problem for the life science industries.
10 Chapter One
and price. If it is labor time that constitutes value, as Ricardo argued, it is
only by virtue of its abstraction from all particular use values of labor, its ge-
neric exchangeability as “abstract, socially average” time (Marx 1990 [1867]:
129). To “develop the concept of capital,” Marx writes in the Grundrisse, “it
is necessary to begin not with labor but with value, and, precisely, with ex-
change value in an already developed movement of circulation” (1973: 259).
It is not through some natural transformation of use value into price, but
retroactively, through the abstraction of money in circulation, that the value
of labor is determined.
Having established the retroactive logic, however, Marx insists that the
determination of the value of labor is a political decision, the outcome, that
is, of ongoing conflicts between labor and capital. Labor’s value contains
a distinct “historical and moral element,” manifest in the particular forms
of temporal measure that govern labor in any given moment (Marx 1990
[1867]: 275). If exploitation is essentially a form of temporal discipline, it is
not surprising that labor struggles have historically targeted the social orga-
nization of time—not only the length of the working day, as Marxists have
traditionally pointed out, but also the division between the time of produc-
tive labor (work) and the time of reproductive labor (life), and the social dis-
tribution of accidental time or risk.
Thus far, our reading of Marx is closely aligned with that of theorists
such as Isaak Rubin and Moishe Postone, who point to the centrality of tem-
poral abstraction in Marx’s labor theory of value. We differ from these per-
spectives, however, by insisting that the abstract and the material (indeed,
embodied) dimensions of labor cannot be theorized in isolation. In their
attempt to distinguish Marx’s theory of labor from the substantialist con-
ceptions of the classical liberals, these theorists seek to divorce the concept
of abstract labor time from the historically specific, physiological forms as-
sumed by the concrete labor process in any given order of production. In so
doing, however, they risk reinstating a reductive, ahistorical conception of
the “physiological” in its place.8
In any event, we would suggest, the structural categories of Marx’s theory
of value cannot be so easily abstracted from the biotechnical conditions of
labor that characterized the mid-nineteenth century. Far from represent-
ing a merely metaphoric aspect of Marx’s thinking, the technical vocabu-
lary of early industrial production shapes the very conceptual framework
of the theory of value, giving rise, for example, to the distinctions between
dead and living labor, variable and constant capital. These distinctions rest
on the assumption that the technical or machinic composition of capi-
12 Chapter One
is contingent, unpredictable, and plastic in the unfolding of biological tem-
porality. The rct is rigorously Taylorist in its application of social statistics
to the biomedical events affecting the massified body of the population, but
it also serves to isolate the unpredictable or contingent biomedical event
(the unexpected side effect, for example) against the background of the nor-
mal distribution. Increasingly (as we will see in chapters 6 and 8) it is the
nonstandard temporality of the contingent event that has come to define the
work of biomedical innovation. With the advent of stem cell biology, cell de-
velopment is no longer understood to follow a predetermined path of pro-
gressively limited specializations but is cultured as a source of flexible, non-
exclusive potentialities, any one of which can be materialized in practice. In
this way, the statistical abstraction of labor that Marx saw as characteristic of
the industrial mode of production now coexists with a form of speculative
materialism, which demands that the contingent event be embodied in the
unfolding of biological time.9
What we are proposing here is a theory of material abstraction that is
neither dialectic nor representational in nature (pace the Marxist theorist
of real abstraction [Colletti 1973]), but experimental and interventionist. As
the “practical” turn in recent science studies might suggest, if the scien-
tific hypothesis is effective, it is not as a theoretical proposition projecting
itself onto an inert matter but as a method for inhabiting and modulating
the already immanent possibilities of living matter (Hacking 1983; Simon-
don 1995; Rheinberger 1997b). The experimental intervention works to sus-
pend, freeze, culture, replicate, reverse, accelerate, slow down, and amplify
the already-existing temporalities of the entities it works with (cell lines,
metabolic processes, tissue cultures), prompting them to become other than
they were in vivo or to “live differently in time,” in the words of Hannah
Landecker (2005). Biomedical technology can be understood as a practice
of controlled decontextualization that is able to provoke unsuspected or as
yet unrealized actualizations from its living materials by exposing them to
novel environmental conditions. In this respect it is always both an abstract
and a material intervention into a spectrum of already available material ab-
stractions; an attempt to modulate the multiple differentiations open to a
particular cell, for example.
In pointing to the importance of the material and experimental dimen-
sion of bioproduction, however, we do not wish to suggest that the creation
of a market in clinical labor is reducible to its technical conditions. As we
will explore in detail in this study, even when the necessary material prem-
ises have long been available, legal innovations such as the tort law concept
14 Chapter One
capital theory, in which workers are constituted as entrepreneurs of their
own productive, and indeed reproductive, capacity. These are crucial pivot
points in the transformation from an industrial regime of statutory labor
protections to a neoliberal regime of reprivatized contractual relations. We
argue that the evolving institutional and legal forms of clinical labor bear
witness to this transformation in the most material of ways.
We then turn to a more specific investigation of the historical and con-
temporary conditions of clinical labor. As we will see, reproductive and ex-
perimental labor emerge from the margins of the Fordist industrial model
and Keynesian welfare state, in the product-testing regimes of the rct and
the various forms of reproductive service performed by the unpaid house-
wife or the paid domestic servant (cook, nanny, or wet nurse). Our analysis
traces the progressive spatial reorganization of clinical labor as reproductive
and experimental services move from the sequestered spaces of the verti-
cally integrated Fordist institution to the distributed spaces of post-Fordist
contract labor. Until the 1980s, clinical trials were conducted within the
confines of the academic research hospital or the prison. During the same
period, the unpaid reproductive labor of the housewife took place within the
sequestered space of the Fordist household. Each of these categories of work
blurred the boundaries between the “free” and the “unfree” contract of labor
and involved more or less coercive forms of confinement or state financing.10
Unpaid reproductive labor was indirectly subsidized by the state through the
institution of the family wage. Prison-based clinical trials represented one of
the few opportunities for earning a wage in prison at a time when there were
severe restrictions on prison labor, and hospital-based trials were subsidized
by the introduction of social insurance for the elderly and the poor (Medi-
care and Medicaid) in the mid-1960s. Located in the peripheral spaces of
the household, the hospital, the warfront, and the prison, these experimen-
tal and reproductive forms of value generation were sharply separated from
the scene of formal industrial labor.
Since the 1980s, however, the institutional spaces of Fordist clinical labor
have been subject to ongoing reform. At stake in the transition from Fordism
to post-Fordism, we argue, is not only the vertical disintegration of national
production and the large firm but also the horizontal contractualization of
services once performed in the confined spaces of the household, the hos-
pital, and the prison. These once internalized labor forces have been sup-
planted by a model of contractual outsourcing that delegates clinical labor
on a case-by-case basis to the independent contractor for in vivo services. It
is during this period that we see the decomposition of the family wage, pre-
16 Chapter One
who routinely endure the most hazardous and contingent of labor condi-
tions. Later-phase trials are increasingly dependent on the growing numbers
of underinsured, chronically ill patients who can access medicines only if
they also agree to engage in clinical trials. Under post-Fordist conditions of
generalized labor informalization, clinical trial work is contingent labor par
excellence—labor that is defined by the “freedom” to bear risks of the most
visceral kind. It is this problematic of experimental labor that we will exam-
ine in the third part of the book, “The Work of Experiment: Clinical Trials
and the Production of Risk.”
In each section, we begin with a historical account that sets out the con-
ditions for emergence of reproductive and experimental clinical labor in the
twentieth century. We then give an account of the transnationalization of
clinical labor, as both reproductive services and clinical trial work are off-
shored to less expensive locations beyond the borders of northern Europe
and North America. We then consider the development of distributed, ex-
tensive forms of clinical labor in the more innovation-driven sectors of the
bioeconomy, examining the role of women as donors of “surplus” reproduc-
tive tissues in the stem cell industries and of patients as self-experimental re-
sources for pharmaceutical innovation. In what follows, then, we provide an
account of clinical labor that simultaneously maps its historical conditions,
its political economy, and its contemporary trajectory. We hope to show that
this form of work, far from representing an exceptional or extreme mani-
festation of the underground economy, is emblematic of the conditions of
twenty-first-century labor.