Melinda Cooper and Catherine Waldby, Clinical Labor: Tissue Donors and Research Subjects in the Global Bioeconomy, Duke University Press, Durham, 2014, 296 pages, $24.95 paperback, ISBN: 978-0-8223-5622-6.

Biotechnology and the post-Fordist regime of accumulation present a fundamental challenge to Marxist conceptions of the valorization of labor—a challenge that requires empirically grounded and theoretically creative engagement. Melinda Cooper and Catherine Waldby provide such a contribution in their book Clinical Labor. Through an exploration of the empirical sites of assisted reproductive technology (ART), gestational surrogacy and clinical trials, they argue that the embodied, biological, clinical labor of human subjects is integral to the post-Fordist regime of labor.

Their work engages a wide range of scholarship, from explorations of neoliberal subjectivity (Rose, 2007) and biosocialities (Sunder Rajan 2008) to Italian autonomist work on post-Fordist labor (Lazzaranto, 1996; Fumagalli, 2007). Specifically, Clinical Labor offers contributions to several audiences: for political economists, Cooper and Waldby show that viewing the market in human tissue as a simple case of commodification or as a dichotomy between the gift and the commodity or between production and reproduction is not adequate; instead they suggest rethinking the Marxian labor theory of value (LTV) by introducing the concept of clinical labor. To those investigating bio-politics, technology, or socialities, Cooper and Waldby illustrate the deep entanglements between racialized biopolitics "beyond the state" and the post-Fordist regime of labor. Geographers will benefit from their spatialization of the uneven distribution of bodily risk along lines of race, class, and gender as well as between post-industrial and emerging economies. In light of these diverse engagements, we see their contributions as threefold: first, bringing together insights from Marxian theory and science studies to build a clinical LTV; second, placing biopolitical theorizing of biotechnology in context of the political economy of neoliberalism; and third, making a convincing critique of bioethics by showing how its operation is internal to post-Fordist development.

In Chapter One, Cooper and Waldby expand Marx’s LTV to explain the valorization process in post-Fordist clinical labor. This choice departs from their previous research (e.g. Waldby & Mitchell, 2006; Cooper, 2008) by taking such an explicit focus on labor instead of "living commodities" and "living capital." Stressing the importance of viewing Marx’s original contribution in its historical context, they note that the emergence of statistical methods with the Industrial Revolution facilitated the statistical abstraction that allowed Marx to theorize labor as abstract, and crucially, averagelabor. In post-Fordist clinical labor, this statistical abstraction becomes material abstraction, with new biotechnologies allowing modification of the direction and temporality of biology. In making this claim they draw on speculative materialism and Ian Hacking’s (among others) conception of the experiment as a way to assess and direct the inherent possibilities of biological matter (see, for example, Hacking, 1983). Cooper and Waldby’s use of speculative material abstraction makes clear that their contribution is not simply orthodox Marxist or post-structuralist: their theory is “neither dialectic nor representational” (page 13). Rather, their science studies approach stresses a materialism that is “experimental and interventionist” (page 13), a choice that is crucial for their argument that the value of clinical labor in post-Fordism needs to be understood at a biological and speculative level.

As students whose assumptions have been challenged by posthumanism, we were surprised at the humanist focus of Cooper and Waldby’s approach. While their restricted focus on human subjects is likely a choice of scope and is itself deserving of a thorough investigation, their attention to historical detail hints at the importance of animals in the bioeconomy, with a particularly telling section at the beginning of Chapter Three (35-42) tracing the importance of herd management in developing artificial insemination techniques. However, if we take Haraway’s (2007) analysis to heart, the co-development of human and nonhuman ARTs must necessarily entail a blurring of the boundaries of the human: if the use of ARTs entails labor on the part of human research subjects, does it also entail labor on the part of nonhuman subjects? This specific gap highlights the general fact that Clinical Labor does not engage with recent productive debates centered around theorizing nonhuman labor within Marxism, including posthumanist approaches drawing on relational ontologies such as actor network theory (e.g. Gareau, 2002). In the context of the rest of the book, Chapter One makes us question how a speculative understanding of materialism and a focus on the valorization of biological labor cannot engage with the central role nonhumans (especially nonhuman animals such as livestock) have played in capitalist bioeconomic development (Shukin, 2009). For this reason, a posthumanist approach building on or engaging with Cooper and Waldby’s work could be very productive.

Fundamental to Cooper and Waldby’s rationale for expanding the LTV are the ways in which the development of a post-Fordist organization of clinical labor entails the outsourcing of risk to the individual worker. The authors analyze the work of Gary Becker and other Chicago school theorists to show that clinical labor is not merely coterminous with post-Fordism, but that biological commodification was fundamental to its genesis, furnishing a strategy of accumulation that responded to the folding of the Fordist household. Here they link this development with the 19th century legal principle volenti non fit injuria, "to the willing person no injury is done," wherein contract law facilitates exploiting the products of the body while deflecting entrepreneurial and bodily risk onto the clinical laborer.

In this discussion of the importance of contract law in supporting the downward shedding of risk onto clinical laborers, Cooper and Waldby develop one of the most intriguing arguments made in Clinical Labor: that the bioethical framework does not just represent an external limit designed to minimize unethical exploitation, but rather rests on and ultimately supports the neoliberalization of clinical labor markets. The golden standards of bioethics, including informed consent and the focus on compensation for volunteerism instead of wages for labor, do not protect human subjects from coercive or exploitative relationships in the international market for clinical labor. Cooper and Waldby’s post-Fordist clinical laborer is "free" to sell her bodily materials with informed consent in the same way that Marx’s laborer is "free" to sell her labor-power for wages under contract (page 14).

The outsourcing of risk enabled by a bioethical framework is clearly exemplified in the third and final section of the book, a historical and theoretical investigation of clinical drug trials. The authors continue their critique of Chicago school economics by pointing out that Frank H. Knight’s conception of profit as compensation for entrepreneurial risk hides the fact that risk in clinical labor is borne not by "innovating" Big Pharma companies, who are protected from the financial risks of speculation in the US by the 1995 "Safe Harbor" clause, but rather is embodied by human research subjects. This distribution of risk, moreover, has an uneven geography. Chapter Seven argues that the US model of clinical trials drawing on precarious and un—or under—insured labor has been exported to emerging economies. This outsourcing is rationalized as a solution to the perceived recruitment crisis in human research subjects from affluent states and is facilitated through transnational contract research organizations and globalized standards for drug testing and approval.

Geographers will find various other spatial patterns to latch onto as well. Chapter Four addresses the international clinical labor market and its political dynamics across space by examining the phenotype-based European oöcyte market and the price-based Indian surrogacy market. Their most interesting contribution here is how these markets amount to a "commercial reproduction of whiteness." Since gestational surrogacy makes no genetic contribution, the market incentivizes outsourcing this form of labor to less-expensive Indian surrogates; when it comes to oöcytes, however, western European buyers often source them from eastern European women who provide phenotypically desirable (white) genetic material. The reader is also provided an implicit geography of the body. For example, they show how oöcyte provision assumes more bodily risk than sperm production, and they perceive surrogate mothers as—quite literally—embodying the means of production.

If the outsourcing of risk is contingent on a particular historical organization of labor, the more basic (but no less imaginative) proposition that enables this understanding is that all of these forms of (re)production require labor. The development of a bioeconomic market is not merely an extension of proliferating commodification; it is specifically the commodification of products of labor, of in vivo clinical labor beyond conscious human labor (as typically theorized) with the capacity to valorize. Therefore while stem cell industries only attribute productive labor to the experimenting scientists, the authors argue that the largely unremunerated biological material provided by women in the form of afterbirth or dead fetuses, for example, should be understood as unpaid surplus value. Bioethical convention is crucial to hiding this surplus value: clinical labor is constructed as voluntary in the case of gamete donation and even as "motherly" and "caring" in the case of surrogacy.

This intervention begs a recurring question for us: how are we to understand exploitation in clinical labor? While it is central to their analysis, since exploitation of clinical labor is advanced instead of other explanations such as accumulation by dispossession, it is perhaps undertheorized. While numerous empirical sections highlight the ways in which both biological material and human research subjects actively create value that is subsequently appropriated by others, the theoretical analysis present in Chapter One’s clinical LTV is missing a complementary theory of surplus value. At the end of the book, Cooper and Waldby stress that in vivo production cannot (yet) be fully separated from the laboring human body, meaning that the clinical laborer is exploited directly through their own embodiment. They end by suggesting that “it is these terms of exchange that must be redressed if clinical labor is to be undertaken in more equitable ways” (page 228); we would alternatively stress that it is this unique form of exploitation that must be theorized. How is the degree of exploitation determined in clinical labor? Is clinical labor necessarily exploitative if the “contracting self is hostage to their own embodiment” (page 228)? Or does the sway of the international fertility market ensure that clinical labor entails self-exploitation? If not, what does non-exploitative clinical labor look like? A future politics of clinical labor would require such an engagement with exploitation.

It is worth emphasizing at this point that Clinical Labor is more of a conceptual intervention than a prescriptive project in that the authors focus on challenging bioethical convention and political economic categories rather than suggesting particular ways of overcoming the concerns they address. This is patently deliberate—in fact, one of the book’s greatest accomplishments is the many questions it evokes rather than the answers it offers. The further thought it stimulates is decidedly important, and the empirical research that grounds their intervention is rich and engaging. This is an important book for anyone interested in biopolitics and political economy, and Cooper and Waldby’s clinical labor theory of value provides a creative understanding of the post-Fordist regime of labor. 

References

Cooper M (2008) Life as Surplus: Biotechnology and Capitalism in the Neoliberal Era. Seattle: University of Washington Press.

Fumagalli A (2007) Bioeconomia e capitalismo cognitivo: verso un nuovo paradigma di accumulazione. Rome: Carocci.

Gareau BJ (2005) We Have Never Been Human: Agential Nature, ANT, and Marxist Political Ecology. Capitalism, Nature, Socialism 16(4): 127-140.

Hacking I (1983) Representing and Intervening: Introductory Topics in the Philosophy of Natural Science. New York: Cambridge University Press.

Haraway DJ (2007) When Species Meet. Minneapolis: University of Minnesota Press.

Lazzarato M (1996) Immaterial Labor. In: P Virno, M Hardt (eds) Radical Thought in Italy. Minneapolis: University of Minnesota Press, pp 133 -147.

Rose N (2007) The Politics of Life Itself: Biomedicine, Power and Subjectivity in the 21st Century. Princeton: Princeton University Press.

Shukin N (2009) Animal Capital: Rendering Life in Biopolitical Times. Minneapolis: University of Minnesota Press, Minneapolis.

Sunder Rajan K (2008) Biocapital as an Emergent Form of Life: Speculations on the Figure of the Experimental Subject. In: Gibbon S and Novas C (eds) Biosocialities, Genetics and the Social Sciences. London: Routledge, pp 157-187.

‍