Melinda Cooper & Catherine Waldby

Clinical Labor

Tissue Donors and Research Subjects

in the Global Bioeconomy
Clinical Labor
Experimental Futures Technological Lives, Scientific Arts, Anthropological Voices
A series edited by Michael M. J. Fischer and Joseph Dumit
M e l i n d a C o o p e r & C at h e r i n e Wa l d b y

Clinical Labor

Tissue Donors and Research Subjects

in the Global Bioeconomy

Duke University Press Durham and London 2014

© 2014 Duke University Press
All rights reserved
Printed in the United States of America on acid-­free paper ♾
Designed by Courtney Leigh Baker
Typeset in Whitman by Tseng Information Systems, Inc.

Library of Congress Cataloging-­in-­Publication Data

Cooper, Melinda.
Clinical labor : tissue donors and research subjects in
the global bioeconomy / Melinda Cooper and Catherine Waldby.
pages cm — (Experimental futures)
Includes bibliographical references and index.
isbn 978-­0-­8223-­5608-­0 (cloth : alk. paper)
isbn 978-­0-­8223-­5622-­6 (pbk. : alk. paper)
1. Human reproductive technology—Economic aspects. 
2. Human reproductive technology—Moral and ethical aspects. 
3. Medical care—Technological innovations. I. Waldby, Cathy. 
II. Title. III. Series: Experimental futures.
rg133.5.c669 2014
618.1′7806—dc23 2013025654
 Contents

Acknowledgments vii

Part I. What Is Clinical Labor? 1

One. A Clinical Labor Theory of Value 3

Two. The Historical Lineages of Clinical Labor 18

Industrial Order, Human Capital, and the Outsourcing of Risk

Part II. From Reproductive Work to Regenerative Labor 33

Three. Fertility Outsourcing 37

Contract, Risk, and Assisted Reproductive Technology

Four. Reproductive Arbitrage 62

Trading Fertility across Borders

Five. Regenerative Labor 89

Women and the Stem Cell Industries
 Part III. The Work of Experiment:
Clinical Trials and the Production of Risk 117

Six. The American Experiment 123

From Prison-­Academic-­Industrial Complex to the Outsourced Clinic

Seven. Speculative Economies, Contingent Bodies 159

Transnational Trials in China and India

Eight. The Labor of Distributed Experiment 195

User-­Generated Drug Innovation

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

What Is Clinical Labor?

 One

A Clinical Labor Theory of Value

What is labor? The question is increasingly salient to post-­Fordist econo-

mies, as forms of production and accumulation move further away from the
mass manufacture model that defined twentieth-­century industrial capi-
talism. The post-­Fordist economies are dominated by the service sector, by
knowledge creation and the culture industries, by financial markets and in-
formation capitalism—but also by new modes of biomedical production fo-
cused on innovation value and newly defined contractual rights in the body.
These are forms of productivity whose output is no longer the standardized,
mass-­manufactured commodity but, rather, less easily specifiable entities—
brand equity, customer loyalty, trade marks, intellectual property. The indus-
trial model of labor as exhaustible machine and entropic energy (Walker
2007), operationalized through the scientific management of discrete time
and motion units, no longer accounts for the activity of most employees in
the First World economies.
As manufacture is decentered from the former industrial, advanced
economies, the proliferation of these other forms of production throws into
question the established categories of economic analysis. In particular, it
raises the question of how to understand the relationship between the labor
process and the production of value when both domains are disentangled
from mass manufacture, with its tangible use values and predictable econo-
mies of scale. While the financialization of economies has directed a great
deal of critical attention to the ever more mercurial play of speculation in the
creation (and more recently the destruction) of capital value, a growing body
of scholarship is also engaged in rethinking the category and subjectivity of
labor and its modes of productivity. Yet few have explored the new forms of
embodied labor (surrogacy, the provision and sale of body tissues, partici-
pation in clinical trials) that have proliferated at the lower ends of the post-­
Fordist biomedical economy. This book intends to investigate these forms
of labor as central to the biomedical innovation process, while reflecting,
in turn, on how such a perspective might challenge some of the founding
assumptions of classical, Marxist, and post-­Fordist theories of labor.
Much of the sociological and political economy literature focuses on the
structural changes that typify advanced economies since the late 1970s, par-
ticularly the decline in full-­time, permanent positions for the industrial,
male worker that characterized the Fordist model of production. French
sociologists Luc Boltanski and Eve Chiapello (2005) offer a detailed over-
view of the differences between Fordist labor regimes and post-­Fordist flex-
ible labor. As firms restructured in the 1980s and 1990s to take advantage of
economic deregulation and the transnationalization of supply and manufac-
ture chains, they sought to divest themselves of their internal, permanent
workforce and secure labor on the cheaper terms of just-­in-­time demand.
Hence, companies increasingly resorted to subcontracting out administra-
tive, service, and even professional activities to external contractors and
consultants, substituting fixed-­term for long-­term labor contracts. The ge-
neric post-­Fordist worker is no longer the employee, tied to the firm by a
long-­term contract of service, but the independent contractor, who moves
from firm to firm and from client to client selling contracts for service. As the
standard working day and week are supplanted by intermittent call-­work,
night work, overtime, nine-­day fortnights, weekend shifts, and annualized
work-­times, a plethora of new contractual forms have emerged to constrain
labor to constant work-­readiness and volatile wages (Mitropoulos 2012). By
divesting itself of the long-­term contract of employment, the post-­Fordist
workplace frees itself of the burdens of social insurance and outsources risk
to independent contractors, who become responsible for insuring them-

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;

A Clinical Labor Theory of Value 5

Brown et al. 2011); global markets in pharmaceuticals and genetic data
(Thacker 2005; Petryna et al. 2006); and the political economy of clinical
trials (Fisher 2009; Petryna 2009).
Alongside this literature, and at a much more general level of analysis,
theorists associated with the tradition of Italian autonomist or post-­workerist
Marxism point to the ways in which “the time of life” (that is, the time re-
served for nonwork or unpaid reproductive labor under Fordist conditions)
has become ever more closely enmeshed in the circuits of capital accumu-
lation. The transition to post-­Fordism, they argue, has undermined the con-
ceptual and practical boundaries between the time of work and the time of
life, inaugurating a transition from “capital-­labour” to “capital-­life” (Lazzarato
2004). Most recently, Andrea Fumagalli has proposed the term “cognitive
biocapitalism” as a means of radicalizing the autonomist critique of political
economy. For Fumagalli, “cognitive biocapitalism is bioeconomic production:
it is bioeconomy” (2011: 12). Post-­Fordist capitalism puts life itself to work,
“overcoming the separation between production and reproduction” to constitute
a new form of “biolabor” (12). Under these conditions, any “theory of the
value of work” must become “a theory of the value of life” (12). Suggestive as it
is, the extreme generality of this literature means that it fails to pose the most
salient question—what exactly was “life itself” under Fordist conditions of
(re)production? What, in other words, were its gendered and racialized divi-
sions of labor? And in what sense does the actual production of bioeconomic
value in the knowledge-­intensive life science sector reflect or interact with
these wider shifts in how the scene of reproduction is organized?
Alongside these critical literatures, public policy discourse has identified
the “bioeconomy” as a key site of strategic investment and a decisive stake
in the nascent competitive standoff between the “advanced” postindustrial
economies and the emerging economies of China and India. The Organisa-
tion for Economic Co-­operation and Development (oecd), the European
Union (eu), and now the United States have all published policy directives
designed to foster the emergence of a new long wave of postindustrial eco-
nomic growth based on the integrated “bioeconomy” of the agricultural,
medical, and industrial life sciences (European Commission 2005; oecd
2006; White House 2012). Echoing a discourse that is now at least four de-
cades old, these directives call for a new generation of bio-­based technolo-
gies capable of transcending the limits of industrial, petrochemical produc-
tion in agriculture, transport, and medicine. Much of the focus of this policy
agenda is on the speculative value of as-­yet-­unrealized technological inno-

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

A Clinical Labor Theory of Value 7

its many national and international instruments3 and review processes, is
precisely to protect research subjects and tissue donors from market forces,
enshrining the principles of donation, voluntarism, informed consent, and
freedom from coercion as the guiding principles of ethical research.4 State
regulation of tissue donation and human subject experimentation routinely
stipulate that the donor or volunteer should be compensated rather than
paid a wage and that such compensation should not represent a form of co-
ercion or undue influence.
Nevertheless, as we demonstrate at length in this study, these key ele-
ments of bioethical regulation have proved remarkably adaptable to the
task of governing an informal clinical labor market. In many of the cases we
examine, the ethical insistence that the biological should not be waged only
serves to facilitate atavistic (yet fully functional) forms of labor contract and
desultory forms of compensation. Even in the mid-­twentieth century, we
argue, bioethics served to place human subject experimentation and tissue
donation under an exceptional regime of labor, one that justified various
exemptions from the standard protections of twentieth-­century labor law.
Ironically, as the protections offered by the statutory labor contract become
more residual, the precarious nature of clinical labor increasingly resembles
other kinds of informalized labor in today’s market.5 Throughout this book,
therefore, we have sought to include bioethics within our field of analysis
rather than presume its categories as points of departure. As such, we re-
contextualize the claims of bioethics by considering its historical relation-
ship to labor law, contract, tort, and social welfare, and the particular ways it
intersects with these more familiar instruments for regulating the economic
risks of workers.
We recognize that the category of labor cannot account for all the circum-
stances in which patients donate tissues or participate in clinical trials, par-
ticularly when these exchanges take place primarily within a well-­regulated
and well-­insured therapeutic system, as does much solid organ donation and
certain classes of hospital-­based clinical trials for cancer drugs, for example,
which offer last-­resort, fully insured forms of care. Rather, we suggest that
such services should be regarded as “labor” when the activity is intrinsic
to the process of valorization of a particular bioeconomic sector and when
therapeutic benefits to the participants and their communities are absent or
incidental. Indeed, much clinical labor consists precisely in the endurance
of risk and exposure to nonpredictable experimental effects that may be ac-
tively harmful, rather than therapeutic. We also include the situation where
clinical labor is performed in exchange for health care, reconfigured as an

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.

A Clinical Labor Theory of Value 9

 This constitutive blind spot regarding in vivo production is also to be
found in contemporary critical studies of the labor process. Even the most
interesting theories of postindustrial labor, those that point to the centrality
of the immaterial, cognitive, or affective within post-­Fordism, ultimately
paper over the divisions of labor that exist within the postindustrial innova-
tion economies (Lazzarato 2002; Fumagalli 2007). In this book, we wish to
explore the legal, social, and technical forms of value production that have
converged to enroll in vivo biological processes (from metabolism to sper-
matogenesis and gestation) in a labor relation. In what follows, we turn to
Marx’s labor theory of value and consider its potential usefulness (and limi-
tations) for thinking through the question of bioproduction today.

Bioproduction and the Labor Theory of Value

For Marx, writing in the first volume of Capital, “free,” contractual wage
labor is to be found wherever the worker seeks to sell, for a limited period
of time, “the living-­power which exists in his own living body” (Marx 1990
[1867]: 272). Marx describes labor-­power as a “curious commodity,” unique
in that it is “a source not only of value, but of more value than it has itself”
(1990 [1867]: 301). It is this incipient temporal disjuncture that capital avails
itself of when it distinguishes between the “socially necessary time” needed
to maintain the life of the worker (hence the minimum wage payable for the
worker’s time) and the labor time it appropriates free of charge, as a source
of surplus value. Decisive for understanding the enigma of labor is Marx’s
insistence that the determination of “socially necessary labor time” is the
outcome of ongoing political struggles. It follows that there is no “law of
value” in the sense of some transcendental or natural equilibrium regulat-
ing the relationship between price and labor. The calculation of the price of
labor must be understood as historically contingent yet fully operative as an
instrument of discipline.
Here we follow those theorists who understand Marx’s theory of value as
an immanent critique, not an extrapolation or revision, of the labor theory
of value developed by his classical liberal predecessors (Rubin 1972; Elson
1979; Postone 1993). Adam Smith identified labor as the ultimate, transhis-
torical source of all social wealth, while David Ricardo, revising Smith, pos-
tulated that it was labor time that constituted both the source and measure
of exchange value. For Marx, on the contrary, there is no intrinsic value to
labor that we might want to recognize or valorize against the fetishisms of
the market, and there is no automatic correspondence between labor time

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-

A Clinical Labor Theory of Value 11

tal is necessarily inanimate and that the human or variable component of
capital resides in the “living labor” of the worker’s body, conceived as an
organic whole. Early twentieth-­century developments in biomedicine fun-
damentally challenge these categories by inventing what Hannah Landecker
(2007) has called “living technologies”—in vitro tissues and cell lines that
are both living and machinic in the sense that they can be cultured outside
the body and form part of the technical composition of science. The twenti-
eth century brings the production process inside the body and puts organs,
blood, and cell lines into circulation outside the body, scrambling the classi-
cal Marxist distinction between the living and the dead (Cooper 2002). In
earlier work, we theorized the emergence of living commodities (the com-
mercial exchange of organs, blood, and cell lines outside the body) and living
capital (the patented cell line as generative of surplus value) (Waldby and
Mitchell 2006; Cooper 2008). In this book, we trace the relocation of the
labor process to the suborganismic level of the body, via the mass experimen-
tation of randomized controlled trials (rcts) and the contractualization of
assisted reproductive services.
What we are proposing here is not a “biological” labor theory of value in
the classical, pre-­Marxist tradition, as if the ultimate use value and source
of all wealth could be located in the intrinsic generativity of living biology.
Rather, we understand “clinical labor” as the process of material abstrac-
tion by which the abstract, temporal imperatives of accumulation are put
to work at the level of the body. The temporal abstraction that Marx identi-
fied as characteristic of exchangeable labor (and hence the defining feature
of labor under the capitalist mode of accumulation) can also be detected in
the long history of twentieth-­century interventions into the biological body.
We would not be able to speak of “clinical labor” as such without the import-
ing of mass production methods into the agricultural sciences in the early
twentieth century, the development of instruments for culturing living cell
lines outside the body, the use of statistics in the experimental clinical sci-
ences, the invention of methods for suspending and freezing biological time
(cryobiology) in the 1950s, and the perfection of infrastructures for the mass
storage of tissues, organs, and cells (Clarke 1998; M. Edwards 2007; Gaudil-
lière 2007; Landecker 2007). Developed in parallel with the European sci-
ence of labor and American Taylorist methods of time management, each
of these interventions render the biological newly pliable to the exigencies
of abstract, exchangeable, or statistical time. At the same time, and increas-
ingly so with the advent of post-­Fordist methods of flexible specialization,
such biomedical infrastructures also serve to isolate and culture that which

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

A Clinical Labor Theory of Value 13

of informed consent, in the early twentieth century, and the contractualiza-
tion of family law, in the late twentieth century, have played a critical role
in determining when and how these biotechnical possibilities are realized
as labor. In a similar way, the emergence of a financialized mode of biomedi-
cal and pharmaceutical innovation in the early 1980s was not so much the
result of a technical revolution as a studied political maneuver on the part
of private corporations, research universities, and policy elites. The finan-
cialization of the life science business model was enabled by a series of key
regulatory and legal interventions into the realms of patent law, securities
legislation, and consumer protection standards.
We differ from most approaches to the field by understanding bioethics as
a crucial component of the normative and legal infrastructure regulating the
political economy of the life sciences, even when bioethics assumes a principled
opposition to the body’s commodification. Whether it is framed in a liberal or a
human rights register, we contend that bioethics as discourse and practice
is internal to the political economy of the life sciences. Within the market
for clinical labor, for example, we argue that informed consent plays much
the same role that Marx ascribed to the doctrine of the “free” wage contract
under classical liberalism. As such, we are not interested in improving “in-
formed consent” by arguing for more or less “ethical” conditions of consent
or for greater autonomy on the part of the consenting subject. Instead, we
understand “informed consent” as an enabling regulatory condition for the
market in clinical labor, one that has evolved alongside signal twentieth-­
century developments in labor law and social insurance to define the spe-
cific form of “unequal exchange” that governs commercial transactions in
the clinic.

Organization of the Argument

In order fully to realize a historically contextual value theory of clinical labor,
our study engages in a longue durée analysis, which considers the relation-
ship between the modern history of labor as it is conventionally defined and
the shadow history of clinical labor. In the next chapter, “The Historical Lin-
eages of Clinical Labor,” we reframe some of the major transformations in
the organization of twentieth- and twenty-­first-­century labor as moments
in the organization of biopolitical risks and capacities—those associated
with the life risks of illness, accident, and reproduction—as well as mo-
ments in the ordering of production. In particular, we track the move toward
labor outsourcing, the contracting out of services, and the rise of human

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-

A Clinical Labor Theory of Value 15

cipitated by women’s mass exodus from obligatory domesticity and into the
workforce. As the unpaid domestic labor of the housewife is supplanted by
an entire service sector specializing in contract-­based affective, sexual, and
care labor, the biological process of reproduction is itself subject to a form of
(legal, technical, and commercial) fragmentation. Once the technical reper-
toires of midcentury animal reproduction are adapted to human patients via
the development of in vitro fertilization (ivf) and other assisted reproduc-
tive technologies (arts), the processes of ovulation, spermatogenesis, con-
ception, and gestation are opened out to third-­party provision, drawing on
surrogates and gamete suppliers outside the family proper. While many juris-
dictions prohibited the commercialization of reproductive services, others,
particularly in the United States, refused to frame regulations. As a conse-
quence, particular jurisdictions have witnessed the emergence of a repro-
ductive service sector framed almost entirely through private contract law.
It is now possible to outsource discrete moments and functions of the repro-
ductive process to independent contractors beyond the boundaries of the
family and the nation without undermining the legal entity that is the post-­
Fordist family. It is this contradiction between the technological fragmenta-
tion of the family and the corresponding tendency toward its legal reasser-
tion that we will address in the second part of the book, “From Reproductive
Work to Regenerative Labor.”
During the same period, the prohibition of prison-­based trials, followed
by managed-­care-­inspired reforms of the academic research hospital, com-
bined to push clinical trials into the private sector. The mass institutional
trials of the post–World War II era have been progressively replaced by
private-­contract-­based trials that are brokered and mediated by a new kind
of research institution—the contract research organization or cro. The
long-­term confinements required by Phase 1, first-­in-­human trials now take
place in private research units, while later-­phase trials on patients are per-
formed by private physicians under contract to the pharmaceutical industry.
In keeping with these institutional shifts, the contractual conditions that
shape clinical trial work have also changed, even while the racial and class
profile of the clinical trial subject remains remarkably static. The pharmaceu-
tical industry now looks for its research subjects outside the state-­subsidized
spaces of the prison and the hospital, locating new sources of experimental
labor in the various forms of risk exposure generated by neoliberal labor and
welfare reform. Today, contract research organizations habitually recruit
Phase 1 research subjects from among the underemployed, day laborers, ex-­
prisoners, and undocumented migrants, precisely those classes of worker

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.

A Clinical Labor Theory of Value 17

 Notes

One. A Clinical Labor Theory of Value

1 The exceptions here are recent fieldwork studies that have provided important ac-
counts of particular sectors, including gamete vending (Almeling 2011; Vora 2011)
and Phase 1 clinical trial work (Sunder Rajan 2008).
2 Bioethics is a broad discipline, as well as a regulatory discourse, and we acknowl-
edge that a critical and feminist bioethical scholarship has pursued some of the
questions and issues we raise in this book (e.g., Elliot 2008; Dickenson 2007;
Baylis and McLeod 2007).
3 For example, the Nuremberg Code (1949), the Declaration of Helsinki (World
Medical Association 1964), the Belmont Report (National Commission for the
Protection of Human Subjects of Biomedical and Behavioral Research 1978), and
the European Convention on Human Rights and Biomedicine Council of Europe
(1997).
4 The Belmont Report, for example, stipulates that “informed consent requires
conditions free of coercion and undue influence. Coercion occurs when an overt
threat of harm is intentionally presented by one person to another in order to ob-
tain compliance. Undue influence, by contrast, occurs through an offer of an ex-
cessive, unwarranted, inappropriate or improper reward or other overture in order
to obtain compliance” (National Commission for the Protection of Human Sub-
jects of Biomedical and Behavioral Research 1978).
5 This resemblance is not lost on popular current affairs media, where more and
more documentaries and news items feature sensationalized accounts of impov-
erished students or the newly unemployed selling eggs or signing up for Phase 1
clinical trials to make ends meet in the post–financial crisis world. Indeed, the
self-­evidence of such clinical labor is treated in the news media as an index of the
new economic realities faced by young people in particular. Nevertheless, it re-
mains opaque to most bioethical analysis.
6 Here we limit ourselves to a brief survey of figures available for assisted reproduc-
 tive markets and clinical trials in the United States, taking into account the fact
that little data exists for some of the less-­regulated kinds of clinical labor, such as
the sale of oocytes and sperm. According to research conducted by the National
Institutes of Health (nih) and the Center for Information and Study on Clini-
cal Research Participation (ciscrp), in 2006, close to 800,000 Americans were
enrolled in government-­funded clinical trials and close to 900,000 in industry-­
funded trials (Phases 1–3) (ciscrp 2011). The market value of the US infertility
services sector was estimated to have reached �4.4 billion in 2008 (Marketdata
Enterprises 2009). As of 2008, the United States housed more than 100 sperm
banks and 483 fertility clinics, most of them run by small medical practices or
hospital-­based clinics (although there is one large provider chain, IntegraMed,
that operates several dozen clinics). The Centers for Disease Control and Preven-
tion (cdc) reported that 17,697 donor eggs were transferred to infertile women in
2009 (Centers for Disease Control and Prevention 2011). art produced more than
50,000 children per year via 142,000 ivf procedures (Marketdata Enterprises
2009).
7 According to the common law doctrine of res nullius, persons do not have property
rights in their own bodies and cannot sell a part of themselves. The human body
and its parts are considered beyond commerce and outside of contract, and once
tissue has left the body, it is understood to belong to no one. Patent law in the life
sciences relies in turn on a notion of property right derived from Locke—property
rights can be established by adding labor to unimproved or natural land or materi-
als, transforming them into useful entities. For an extended treatment of the Lock-
ean idea of labor and property see Waldby and Mitchell 2006.
8 This move is most flagrant in Rubin (1972), who dismisses the “energetic” con-
ception of labor as an ahistorical reading of the labor theory of value. What Rubin
misses is the very historicity of the concept of “energy,” its close connection to the
thermodynamic science of industrial production, and its deployment as a category
of labor discipline. In other words, a historically sensitive perspective on the ma-
terial abstraction of labor would need to investigate how “energy” (or, for example,
affect) come to constitute the socially determined measure of labor value within a
given order of production. See Vatin 1993 for an example of this kind of perspective.
9 We use the term “speculative materialism” in a critical sense. From our perspec-
tive, much of the current philosophical literature on “speculative materialism” sub-
stitutes ontology for critique and fails to engage with its proximity to the contem-
porary form of capital’s “material abstraction.” See, for example, Bryant et al. 2011.
10 Throughout this work, we deploy the concept of “free wage labor” in the critical
sense intended by Marx. In other words, we insist that Marx’s theory of labor was
a critique of liberal political economy—and therefore a critique of liberal theories
of freedom of contract—not a continuation of Ricardian political economy, as the
more technocratic and statist elements in the Marxist tradition would later come
to interpret him. We recognize that Marx made “free wage labor” the target of his
critique precisely because it escaped the critical purview of nineteenth-­century
liberals, who were quite happy to denounce the unfree labor of the slave but

230 Notes to Chapter One

 stopped short of examining the exploitation involved in freedom of contract. How-
ever, Marx’s almost exclusive critical focus on the free wage contract means that
he neglects the various forms of unfree labor—bondage, indenture, and cover-
ture—that continued alongside the expansion of industrial labor throughout the
nineteenth century. At his most reductive, Marx dismisses such forms of unfree
labor as residues of an archaic feudal order, destined to be overcome by the long
march of history. We argue instead that free and unfree labor presuppose each
other and are equally constitutive of the capitalist labor relation. For an extensive
and illuminating discussion of this question, see van der Linden 2008.

TwO. The Historical Lineages of Clinical Labor

1 The Court interpreted the Due Process Clause of the Fourteenth Amendment, a
post–Civil War Reconstruction amendment, as enshrining freedom of contract.
2 Lieberman writes, “Southern Democrats, committed to preserving both racial seg-
regation and the distinctive regional labor market, found themselves in a majority
coalition during the New Deal with urban Northerners and organized labor, who
were demanding a social democratic program of national social and employment
policy. This coalition . . . created a national welfare state aimed at its constitu-
ent class groups, industrial workers and white Southern planters, and it did so by
building new institutions on a foundation of racial inequality. . . . [The act created
exclusions,] in some cases by excluding the occupations in which most African
Americans worked [agricultural and domestic workers], in others by drawing strict
eligibility criteria that many African Americans could not meet, and in still others
by preserving local autonomy” (Lieberman 1998: 24–25).
3 What we are referring to here is the “canonical” version of the labor theory of
value expounded in the first volume of Capital. We recognize that, in other texts,
Marx proposes a more nuanced understanding of the full spectrum of contractual
and social conditions at play in capitalist labor relations. In his Theories of Surplus
Value, for example, Marx argues against Adam Smith that “productive” (surplus-­
value-­generating) labor extends beyond the material production of commodities
to include the processlike performance of “personal services.” By this definition,
all kinds of service work ranging from the lowest forms of menial, domestic, and
sexual labor (“the mass of menial servants,” “cooks,” “prostitutes”) to the high-
est forms of professional, bureaucratic, or scientific labor (“state officials, military
people, artists, doctors, priests, judges, lawyers”) can potentially be considered
“productive” labor if they enter into a labor relation that generates surplus value.
See Marx 1969: 165, 174. Here again, however, Marx fails to account for the persis-
tence of domestic servitude within the capitalist order of production, by classifying
tasks performed on a personal basis within the household as feudal remnants.
4 In Australia, the Commonwealth Court of Conciliation and Arbitration awarded
the first male breadwinner wage in the Harvester Judgement of 1907.
5 For a detailed account of the various theorists associated with Chicago School neo-
liberalism, see Horn et al. 2011.

Notes to Chapter Two 231