Abstract
We are gratified to have this opportunity to engage with our reviewers. One of our aims as we wrote Clinical Labor was to bring together the literatures in labour studies and social studies of biomedicine and see how their different understandings of production, value and social order might inform each other. We were struck again and again by the absence of such a dialogue, and by our sense of the critical and analytic possibilities offered by a mutual interrogation. This absence, however, meant that we had to more or less start from scratch, and create a critical architecture adequate to the task. In the process, of necessity, we had to rethink the categories of life and labour extensively, and it is perhaps this far-reaching re-examination which will give the book its lasting impact. Our reviewers here each grapple with this architecture in different ways, and it is very exciting to see the insights generated in the process, and to get a sense of the different possible trajectories and destinations for the work.
Carol Wolkowitz takes perhaps the widest view, and her points regarding the complexity of labour history, the many exceptions and cognate practices to the account we provide in Clinical Labor are well made. We would simply respond to the effect that, in investigating the 19th and 20th century history of labour, and in particular the broad relations between production and reproduction, we were interested in how labour looked from a biopolitical point of view. Our account is not exhaustive, but we hope that it is sufficiently innovative as to provoke some extended considerations of the specific historical relationships between clinical labour and the other forms of body work she describes.
Kristin Peterson, working more directly from a biopolitical point of view and a specific knowledge of the pharmaceutical industry, particularly highlights the way Clinical Labor opens out the norms and assumptions of medical research ethics and the operation of Institutional Review Boards to a novel analysis. The continuity between bioethically endorsed participation in medical research and various forms of undocumented and precarious work is a dynamic we were keen to demonstrate, and we are pleased to find that our analysis is persuasive.
Finally, we would like to engage more closely with Alys Weinbaum’s review and her specific criticisms concerning our neglect of the reproductive economy of slavery. Drawing on Angela Davis’ article ‘Surrogates and outcast mothers’ (1998), Weinbaum argues that ‘contemporary forms of reproductive exploitation (surrogacy and oocyte vending)’ are continuous with ‘400 years of human reproductive bondage’.
Like much of the literature on surrogacy and American race relations, Davis’ article appears to take its cue from the Johnson v. Calvert case of 1993, which dramatically foregrounded the possible racial configurations of commercial surrogacy at a time when such transactions were relatively rare. The case involved an African American surrogate named Anna Johnson, who after the birth of the child wished to retain custody, and a white commissioning couple, the Calverts, who provided both sperm and oocytes. The Supreme Court eventually decided in favour of the Calverts on the grounds that ‘specific performance’ of contract was legitimate in surrogacy arrangements. At the time, many feminists read Johnson v. Calvert as presaging the advent of an assisted reproductive market based on the reproductive labour of African American women. In subsequent years, this intuition has produced a vast critical literature very much in tune with Weinbaum’s argument that commercial surrogacy represents the continuation of ‘400 years of human reproductive bondage’.
We are reluctant to draw the same conclusion for two reasons. Firstly, the history of African American labour after emancipation cannot be usefully understood as a simple continuation of slavery. Although African American women and men have experienced the almost continuous imposition of unfree labour (from convict leasing and domestic servitude in the post-Reconstruction era to prison labour, military service and workfare in the present), these regimes are distinct from slavery and demand their own forms of analysis. Slavery is not debt peonage, debt peonage is not workfare – and it seems to us that any conflation of these terms does little to enable political critique.
Secondly we would point to the fact that very few US surrogates today are women of colour. In their exhaustive review of the empirical literature, Busby and Vun found that ‘most women who agree to become either gratuitous or commercial surrogates are Caucasian, Christian, and in their late 20s – early 30s’ and of modest as opposed to low-income (Busby and Vun, 2010: 42). Also, in an earlier review, Ciccarelli and Beckman concluded that women of colour were in fact ‘greatly under-represented as surrogate mothers’ (Ciccarelli and Beckman, 2005: 31). These findings sit rather oddly with the vast critical literature anticipating a surrogacy market based on African American women’s labour and certainly do not suggest a simple continuity between the reproductive economy of slavery and commercial surrogacy. It is undoubtedly true that the racial history of domestic servitude has left an indelible mark on the post-Fordist economy, but arguably its legacy is to be found in the workfare programmes that employ minority women in the low-wage service sector, not in the commercial surrogacy sector.
For similar reasons, we are equally sceptical of the argument that contemporary clinical trials can be neatly derived from the surgical and medical experiments of 19th century scientists. Weinbaum thus argues that slaves ought to be regarded as among the first research subjects, pointing to the use of slave women in the development of the speculum. This is no doubt true. We could point to many other historical instances in which slaves, prisoners or the insane were used as research subjects in 19th century medical experiments. Such continuities of racial oppression are hardly surprising. However, the medical experiments Weinbaum is referring to predate the invention of the randomized controlled trial in the 1930s and the rise of a mass pharmaceutical industry after World War II, and therefore participate in a very different epistemological and economic regime to the one we are tracing. Again, the continuities of racialized labour are not in question here, but a too rapid conflation of historical regimes of labour and medical science does nothing to illuminate the evolving conditions of oppression.
Thus, the empirical data on the contemporary clinical trial industry in the US does not support the hypothesis that African American women are over-represented among research subjects. In fact, the opposite is true: as with commercial surrogacy, African American women are under-represented in most clinical trial phases, even Phase 2 studies where women otherwise dominate. Indeed, it is this recent history of under-inclusion (rather than over-representation) that can be understood as one way in which African American women’s health is not taken into account within contemporary economies of health. If the second part of our book appears to neglect women, this is because women in general are marginalized from the most dangerous pharmaceutical trials, that is, Phase 1 first-in-human trials on ‘healthy’ subjects. This is not the result of any erasure of gender on our part but rather because a certain kind of ethical protectionism, along with fears of litigation, have actively excluded women from trials that might harm the foetus, ever since the thalidomide scandal of the 1960s.
In fact, it is African American and other minority men who dominate in Phase 1 trials in the US today, a phenomenon we see as continuous with practices of ‘prisonfare’ and high-risk agricultural work undertaken by undocumented migrants. Certainly women are to be found en masse in biomedical prevention trials for infectious disease, most of which are carried out in sub-Saharan Africa, South-East Asia and Latin America. However, Clinical Labor is specifically concerned with the dominant kind of trial – that is, pharmaceutical trials for lifestyle and chronic and non-infectious disease – and the demographics of this particular regime do not support the kind of historical deductions that Weinbaum wants to make.
Finally, we would like to highlight what we see as the dangers of historical conflation in the analysis of women’s labour. After all, women’s labour – in particular, the embodied labour of lower class or minority women – seems to attract a disproportionate burden of metonymic slippage. Both the critical and popular literature on surrogacy abounds with facile conflations between prostitution, ‘body’ trafficking and slavery. Typically these kinds of conflation lead to the worst kinds of humanitarian or protectionist intervention and do little to illuminate the specific forms of exploitation at work in particular labour regimes. The danger of deriving the contemporary surrogacy market from slavery is that it reproduces the same confusion and obscures the actual gender and racial dynamics of clinical labour as it is organized today.