Innovative health technologies increasingly involve therapeutic use of human biological material (Waldby and Mitchell, Reference Waldby and Mitchell2006). Well-entrenched transplant technologies have for years used, for example, organs, arteries, blood, plasma, bone, bone marrow, skin, and cornea; and new technologies currently under development in the fields of tissue engineering and regenerative medicine find new uses for biological material similarly originating in the bodies of living or deceased persons and fetuses. Exchange of such material potentially conflicts with a prominent moral ideal according to which human bodies and their parts are beyond trade (Munzer, Reference Munzer1993). This ideal typically takes the form of a distinction between human persons and commodities, which gained prominence and public support more or less concurrently with the rise of what Marx described as ‘the capitalist mode of production and the abolishment of slavery’ (Hoeyer, Reference Hoeyer2007).
The property status of body parts has never been clear (Charo, Reference Charo, Youngner, Anderson and Schapiro2004), but since Caius (second century ad) reference has been made to the body as nullius in bonis (for the benefit of no person) in different legal systems to indicate that its parts should not be sold (Skegg, Reference Skegg1975). Though many body parts nevertheless have been sold over the years, the moral ideal designating the body as beyond trade has gained increasing legal authority. Organ trade is illegal, and with the European Union (EU) Tissues and Cells Directive (2004/23/EC), which is harmonizing European standards for procurement and distribution of tissue for therapeutic use, the EU has enacted explicit policy to work towards ‘voluntary and unpaid donation’ and to make member states ‘encourage a strong public and non-profit sector involvement’ in the procurement of cells and tissues (preamble Article 18). In some countries exchange systems for blood and plasma have relied on monetary incentives to donors for many years, but even with blood and plasma the global trend is to revert to unpaid donations (Copeman, Reference Copeman2005).
How is an economy organized when the substance changing hands is not supposed to be sold? When and how does money change hands and following what logics? These are important questions for a health sector that increasingly relies on health technologies using bodily material as therapeutic tools. Some studies claim that, though donors receive little or no remuneration, due to attempts to keep body parts beyond trade, body parts nevertheless are traded on literal markets where everybody else gains (Cheney, Reference Cheney2006; Kimbrell, Reference Kimbrell1993). However, I suggest that we might better grasp how exchange systems deal with body parts if we do not presume that the moral ideal and its increasing number of legal manifestations merely mask what is really a ‘market’. We need to understand how the moral ideal influences the mode of exchange. And we need to understand the financial arrangements that characterize the procurement systems that begin with ‘free and voluntary donations’.
From the perspective of science and technology studies (STS), Michel Callon (1988) urges us to explore the phenomenon of exchange in all its materiality: to follow the exchanged objects, the apparatuses of calculation and the institutions engaged in exchange. While focusing more on materiality than is customary in traditional economic approaches, he also draws upon a classical anthropological tradition, highlighting how exchanges are embedded in ways of thinking (Appadurai, Reference Appadurai and Appadurai1986; Bloch and Parry, Reference Bloch, Parry, Parry and Bloch1989; Carrier, Reference Carrier1997; Mauss, Reference Mauss2000; Sahlins, Reference Sahlins and Sahlins1972). Callon specifically suggests studying the way in which economy as a discipline performs, shapes and formats the exchanges we come to know as a ‘market’. Economy does not merely deliver a description of a pre-existing market; markets emerge through the prism and tools established by economic theory. Inspired by this point, I suggest that exchanges such as those involving material from human bodies explicitly thought of as non-tradable must be understood in conjunction with the ideas surrounding them. But, whereas Callon focuses on the performativity of economic theory, I focus on the moral ideal that sets human body parts aside from regular trade. In other words, I explore how the no trade dictum performs, shapes and formats exchanges of objects thought of as too human to trade.
A study of the micropractices of such exchanges is a new way of understanding what has become known as tissue economies (Waldby and Mitchell, Reference Waldby and Mitchell2006); an approach that does not take for granted the meaning of categories such as ‘commodity’, ‘price’ or ‘economy’, or presuppose that all exchanges essentially form part of what economists call a ‘market’ (Fabre, Reference Fabre2006; Goodwin, Reference Goodwin2006). This is a way to move beyond the widespread idea that the human body is currently undergoing an increasing commodification. Commodification theory rests on the underlying assumption that all exchange systems essentially form a ‘market’ and deal with the same type of object: the commodity (Andrews, Reference Andrews2005; Dickenson, Reference Dickenson2007; Holland, Reference Holland2001; Kimbrell, Reference Kimbrell1993; Radin and Sunder, Reference Radin, Sunder, Ertman and Williams2005; Scheper-Hughes, Reference Scheper-Hughes2002; Sharp, Reference Sharp2007). The notion of commodification implies that the exchanged object is treated like ‘any other commodity’, and thereby implicitly suggests that such a thing as the ideal, exemplary commodity exists (indeed even the word ‘object’ is problematic here as it designates a ‘not-subject’ though it is the status of being in-between subject and object that seems to contribute to the sense of anxiety in the first place). Commodification theory does not take us very far in terms of alternative ways of understanding the grey area between ‘the free market’ and ‘the inalienable human body’.
Seeing commodification and the traditional economic vocabulary as inadequate for describing most exchanges of human biological material, I pose a different type of question: how is the exchange performed, shaped and formatted by the ideal distinction between human bodies and commercial transactions? I suggest that the distinction contributes to shaping a taboo surrounding the calculation of monetary expenses and compensation schemes, and that it is time to abandon the notion of ‘compensation for expenses’ (recovery costs) and study how exchanges of almost-human objects do take place in practice rather than bemoaning commodification as a sort of moral fact.
It is rarely questioned what makes some types of material human or part of a human body.Footnote 1 But is everything ‘inside the body’ part of the human being? Biologists have long stated that 10 percent of the dry weight of a ‘human body’ is comprised of ‘other’ organisms, but for our survival we are utterly dependent on most of these (Margulis and Sagan, Reference Margulis and Sagan1987). Multiple non-organic entities have also become viewed as part of human bodies (Turkle, Reference Turkle2008); as true cyborgs we tend to comprise many forms of material (Haraway, Reference Haraway and Badmington2000). Entities entering and leaving the space viewed as ‘the body’ therefore develop an ambiguous relationship with the body, making them temporarily human. They are almost-human. It is not clear how many—or which—parts make up the whole (Franklin and Lock, Reference Franklin, Lock, Franklin and Lock2003). And accordingly it is unclear how long after having left a body, a ‘part’ should be exempt from trade. The new technologies of the body are often accused of making the notion of the body and humanness more malleable (Webster, Reference Webster and Webster2006), but perhaps the problem of malleability is more fundamental and also part of our mundane low-tech experiences with body boundaries. In her classic work on human cognition, for example, Mary Douglas (1995) points to the cultural efforts afforded to maintaining the boundaries of the human body in everyday practices such as defecation. And similarly, within the health sector, we need not investigate potentially revolutionizing yet-to-be technologies to observe the effects of the boundary work distinguishing between parts of human bodies and commodities. In fact, for the purposes of this paper I look at a familiar, unfashionable and mundane object: the hip.
The hip, or more precisely the femoral head, is a fascinating object of exchange and relevant for the study of the boundary between human body parts and the commodity realm for several reasons. First and foremost, the femoral head comes in two versions. One is made of metal, also known as a prosthesis. Hip replacements (or total hip arthroplasties) are, with some international variation, among the most common types of elective surgery in developed nations (Merx et al., Reference Merx, Dreinhöfer, Schräder, Stürmer, Puhl and Günther2003). The other version of the hip is made of bone and grown inside the human body. This type (also called the femoral head) is also a desired object of exchange, albeit not as well known as the prosthesis. Nevertheless, successful bone transplants have been conducted since the second half of the nineteenth century and are among the most common types of transplant (Tomford, Reference Tomford2007; Wilson, Reference Wilson1947). Bone can be procured from cadavers and from patients undergoing a prosthetic bone replacement, primarily hip replacements. In the UK it is estimated that bone is used in approximately 7,500 operations a year, compared to an annual rate of 3,000 organ and 2,100 haematopoietic stem cell (bone marrow) transplants (Advisory Committee on the Safety of Blood, Tissues and Organs, 2007). In Denmark approximately 4,000 femoral heads are used in around 1,500 patients a year. In the US in 2006 the number of bone and tendon transplants was estimated at 1.5 million with approximately 22,000 donors annually (Vangsness et al., Reference Vangsness, Wagner, Moore and Roberts2006). Currently, the exchange systems for bone are being restructured to optimize safety, which provides yet another reason for studying this type of exchange. In the US, changes in the Food and Drug Administration (FDA) regulation and Section 361 of the Public Health Service Act are leading to new standards for what is boldly called the ‘tissue bank industry’ (Joyce, Reference Joyce2005), while the EU Tissues and Cells Directive restructures bone banking and other therapeutic tissue collection practices in the EU. The Directive’s stated objective is to ‘ensure a high level of protection of human health’ (Article 1) and to facilitate exchange across the EU. It is relatively cost intensive (expected to cost in the area of £20 million in the first year of implementation in the UK alone, for example).
With huge amounts at stake, with both a metal and a biological version, and with recent attempts to restructure the exchanges, there are many good reasons to choose the (unfashionable) hip transactions for a case study of how monetary aspects are handled at the micro-level when the exchanged object is not supposed to have a price. Hence, I wish to explore how hips are made to travel; how they enter into exchange systems and what form the exchange takes in this very expensive no-trade type of exchange system.Footnote 2 The article builds on fieldwork conducted in Denmark. After a short paragraph on methods, I describe at some length the exchange of human bones procured from patients who have had a hip replacement. I then turn to the metal version of the hip, and show how the unease surrounding commercial exchange of human bone does not reflect any inert human quality of the bone; upon cremation the metal in the prosthesis causes similar types of trouble for the systems of exchange seeking to dispose of it as the bone does for the bone bankers.
Methods
This article draws upon fieldwork in Denmark conducted from March 2007 to June 2009. The methodological principle was to follow the hip through the various venues where it is exchanged and to study relevant agencies, actors and documents regulating this exchange (Marcus, Reference Marcus1995). Key documents examined in this investigation included the EU Tissues and Cells Directive (2004/23/EC) and its Danish transposition, national guidelines and circulars, as well as the local guidelines developed in individual bone banks. Managers of all 17 Danish bone banks were interviewed; most interviews were over the telephone and in some cases various representatives from the same biobank were interviewed more than once to cover different aspects of the procedures.Footnote 3 I conducted two exploratory pilot interviews and then my assistant Sophie Birk interviewed the other bone-bank managers following a semi-structured interview guide. Some bone bankers are medical doctors; others are nurses or laboratory technicians. I participated in meetings among bone bankers and interviewed staff from four different authorities involved in regulation and oversight of the field. To acquire an understanding of the patient’s perspective and to follow the bone from its source to its recipient, I chose one hospital both procuring and using bone. During six non-consecutive days I observed consent procedures during which doctors inform the patient about the operation and acquire informed consent for the donation of bone. Additionally, seven donors were interviewed, either while still in the hospital after the operation or during a control visit six weeks later; and four recipients of bone (two in my office and two over the telephone). All 11 were selected by the hospital on a first-come basis, though for ethical reasons I was not allowed to see patients with cognitive failure, depression and/or substance abuse as an interview was expected to constitute a burden for them. Donors and recipients were also asked about their views on cremation practices (see pp. 250–253). I read newspaper clippings and policy papers about crematorium practices, visited crematoria and interviewed the staff, followed the daily handling of metals from crematoria, and interviewed three people engaged in crematorium politics, as well as the founders of a Dutch company that recycles prosthetic metal.
The material was analysed by indexing it into subcategories reflecting the following analytical questions: Who provides what and who receives what? When and where does money change hands and when and how are monetary aspects referred to? How are such amounts determined? How do exchanging parties view the exchange and what words do they use to describe it? Ultimately, my aim was to give an overall description of the form the exchanges take. I organized this description in terms of steps of disentanglement and exchange. The material was analysed in Danish; only selected quotations were translated into English.Footnote 4 In the following, I seek to unfold this description, beginning with the bone version of the hip, and by asking: for a hip bone to become an object of exchange the bone must be disentangled from the body; when and how is this done?
The bone
Disentanglement: making a part from the whole
It is not every type of bone that can be transplanted: bone excised during operations on indication of fractures or osteoporosis cannot be used, and likewise bone from donors with infectious diseases must be avoided. However, there are no issues of tissue compatibility (unlike organs), and this makes bone a relatively mobile object. Nevertheless, for an object to travel, ‘it is necessary to cut ties between the thing and the other objects or human beings one by one. It must be decontextualized, dissociated and detached’ (Callon, Reference Callon and Callon1998: 19). So when and where does the disentanglement of the hip bone take place? Who provides the bone? In Denmark bone used for allogenic transplants (transplants between different persons) comes almost exclusively from patients undergoing hip replacement operations on indication of osteoarthritis (80% of the hip replacements are carried out on this indication). The patients are typically asked about bone donation during examinations to determine whether they should undergo an operation, and they tend to be anxiously engaged with this issue rather than the questions concerning donation. The interviewed surgeons rarely experienced patients declining donation. Sometimes, however, they would forget to ask and therefore have to get a consent signature after the operation.
Why would a patient want to donate a bone? Ironically, the first step in creating exchange value out of the bone is to designate it as waste. The image of waste is productive in facilitating exchange, as also shown in relation to embryo donation for stem cell research (Svendsen and Koch, Reference Svendsen and Koch2008). Donors embrace this image and highlight the possibility of helping others with something they cannot use themselves. One man said: ‘Really, for me it’s just a piece of waste, right, so I really don’t care. If it can be put to use, it’s fine.’ And a woman explained that as long as they did not take too much or she could not use it herself, the bone was only useful if it could help others. Two men drew reference to potential alternative uses of the bone, which were deemed undesirable, by saying either: ‘I hadn’t expected to take it home to the dog’ or ‘I’m not going to use it for anything—I haven’t got a dog, you know.’ When, in various contexts, I have recounted this image of a dog lying with a hip bone in the living room, people have typically reacted with disgust. Probably it is the humanness of the bone that makes it appear unfit for animal consumption. These reactions demonstrate how designating something as ‘waste’ is not the same as suggesting that it can or should be used ‘for nothing’ or ‘for anything’. Waste is an in-between state of re-categorization; a state in which values transmute but do not just disappear (Hetherington, Reference Hetherington2004; Thompson Reference Thompson1979). Categorizing the bone as waste does not pinpoint and capture the meaning of the bone as such; rather, donors and doctors use the categorization to establish a shared understanding of the implications of a donation: the donor does not stand to lose anything by letting go of the bone. For the bone to be disentangled this sense of certainty must be established; and with it the meaning and value of the bone can remain undefined.
It is not enough to get the bone disentangled from the donor to make it travel. To understand the complexity of bone exchanges one must appreciate the organizational context and the various steps from bone donor to bone user.
Organizational context
To make bones move, a number of people who might not otherwise be particularly interested in bone banking need to be motivated. Thirty years ago, Danish surgeons would personally procure the bone they needed and keep it in a freezer at the ward (outside Denmark bone banking has a much longer history). Today, however, the healthcare sector is structured differently and most of the bone is used in hospitals or wards other than where it is procured: the uncomplicated hip replacements mostly take place in regional hospitals with lower levels of specialization, while the more complicated surgery using bone mostly takes place in specialized university hospitals. Bone banks coordinate the distribution of the bone. If, from a legal perspective, the donor is the initial provider, from the perspective of the bone bank the important provider is the surgeon, because it is the surgeon who must be motivated to procure the bone. Most banks are situated in relatively specialized hospitals and procure bone from several surrounding hospitals. When in turn the bone is to be used, the bank acts as provider. Each bank charges receiving hospitals a fixed amount for a package of bone to ‘cover the expenses of procurement’. All in all, this system implies that surgeons using little bone themselves need to be motivated to procure it for surgeons in more specialized wards, with the bone bank acting as mediator.
To fully appreciate the challenge this poses for bone bankers a further note on context is necessary. In Denmark private hospitals have been promoted since 2001 in what was formerly an almost entirely public healthcare system. One of the means of doing this has been to set time limits on waiting lists and oblige the regional authorities to pay for treatment in private hospitals should the time limit be transgressed. This has moved a considerable part of the elective surgery from which bone can be procured into the private sector and has raised new problems of motivation among the procuring surgeons. It is time consuming and therefore costly to procure bone. It adds to the burden of both patient and surgeon, and, since few specialized operations take place in these private units, there is little incentive for private hospitals to ensure a steady bone supply. How can private hospitals be persuaded to agree to spend time collecting something they do not use?
At one private hospital bone collection recently stopped. The bone bank that usually received bone from this hospital had tried various options to avoid this happening, including their latest effort which was to ‘compensate’ the private hospital for each femoral head collected. They talked about setting a ‘price’ of 500 DKK per head (approximately £50)—which is very little compared to the price of the type of operation during which the bone is procured (approximately 90,000 DKK). This amount is then added to the amount those requesting bone from the bank are asked to pay. So, even if officially bones are not supposed to be traded, money is ostensibly used as an incentive to make bones flow. However, the amount is set too low really to work as a decisive incentive, and the surgeons they seek to influence do not stand to gain anything. Rather than serving as a monetary incentive, the 500 DKK seems to work as a sort of organizational sign of recognition in a language the private hospital is expected to understand. In this way, the logic of the free market is introduced into exchanges, albeit according to a different set of incentives and a public health ethos, and the result is something which is neither ‘market’ nor ‘public health administration’.
Another part of the institutional context is also of importance if we wish to understand why a price tag begins to be associated with the bone. It is not only private hospitals that are compensated for their efforts. As just mentioned, all hospital units are asked to pay a certain amount for each femoral head they request. In the early system, where the individual hospital units kept bone in stock until it could be released to the next patient, this was not so. However, in tandem with specialization and differentiation of tasks between different units, principles from New Public Management (NPM) have been introduced into the health sector. NPM also embodies elements of the ideology of the free market, and involves more detailed financial accounting for each piece of work. Therefore, the bone flowing from low-tech local hospitals to regional bone banks and then on to specialized units at university hospitals involves a budgetary problem. When each unit is run according to individual budgets, each task needs to carry a price too. Thus, a package of bone necessitates the calculation of the costs to be recovered. How, then, is this amount determined?
Finding the right price for a femoral head
The bone-bank managers usually talk freely about the bone as having a ‘price’ and usually state this price in a matter of fact way when asked. The amounts stated varied between 1,500 and 4,500 DKK, partly depending on whether the bank had begun using new and more expensive tests. Bone bankers take care to explain that the price ‘just covers the costs’. But who determines what the relevant costs are and why do different bone banks have such different costs? In most instances, it appears that the ‘cost’ is the price paid in the laboratories for the various tests. This is clearly evident in reference to a new and more expensive way of testing for HIV. Most bone banks have simply added the price for one test (1,400 DKK) to the price of each femoral head—or they plan to do so. The hospital mentioned above, compensating private hospital units with 500 DKK for each bone, passed on this amount to the receiving hospital units. Some claimed to add the price of the container in which, according to the new regulations, the bone must be transported. One bone-bank manager took for granted that the cost of freezers and working hours would be calculated into the price, and another said that even the working hours of the surgeons had been included. However, the inclusion of these extra costs in these two bone banks was contradicted by the fact that the prices were lower in these banks than in bone banks claiming to make no such assessments. In addition, bone banks necessitate physical workplaces, cleaning and maintenance, none of which were calculated into the price. One bone bank stated two different prices for the bone it delivered, 3,500 and 4,000 DKK. It turned out, however, that taking 4,000 DKK was an embarrassing mistake—one staff member had forgotten the correct price. The fact that the higher price had caused embarrassment illustrates that price-setting in this field follows its own rules: it is not strictly related to expenses; it is not a function of demand.
Not only does the price not take into account all the adjoining costs of bone, it also fails to take into account all the bones which must be disposed of either because they are tested (false) positive or because patients do not reappear for any necessary additional testing. When recovering only the cost of the tests (and in some instances additional compensation costs such as the 500 DKK) for each successful bone transfer, the bone bank will have to cover the cost of all the discharged bones without any compensation. Nevertheless, it is stated again and again that the price reflects the cost; that the income balances the expense. It seems, however, that ‘prices’ serve a different purpose than making bone banking into a self-reliant and cost-neutral activity. The notion of cost-neutrality, and the wish to avoid making bone transfers into what could be described as a business, facilitates a relatively relaxed attitude to the calculation of expenses—as long as they are covered somehow. One bone banker admitted that the price was ‘frankly, just a rough estimate’ and several others downplayed the relevance of the price explaining, for example, that ‘it is not that important as long as it all remains within the public authorities’.
A representative of the authorities contributing to the transposition of the EU Tissues and Cells Directive was aware of the ambiguities concerning price-setting and described this very ambiguity as part of: ‘the oil-like disposition that keeps the machinery going’. In fact, he pointed out that expenses cannot be accurately calculated because the agencies compensated have many overlapping tasks, and that, in his experience, negotiating costs always involved one party trying to inflate ‘costs’ to facilitate hidden income, and one party trying to deflate ‘costs’ to make a saving. Complex organizations have many overlapping tasks, using their buildings and facilities for multiple purposes and performing not only bone transfers but also policymaking, documentation, maintenance, research and development, and therefore it is simply impossible to determine an exact cost for every bone. What is striking is the paradoxical coexistence of a casual attitude to price-setting and strictness with the claim that prices only cover the costs. If Callon points to the performativity of the economic discipline in shaping exchanges expected to take the form of trade, we might add that the moral reasoning surrounding human biological material—which is not supposed to be traded—is performative in the calculation of recovery costs. It displaces certain types of reasoning, such as what is related to strict calculation of expenses related to bone recovery, or makes such calculation seem irrelevant. Other types of reasoning associated with NPM nonetheless necessitate balance sheets and audits to keep track of expenses and demonstrate responsible conduct. But the setting of a price hardly delivers the benefits that proponents of the free market ideology tend to associate with price-setting according to supply and demand mechanisms.
Several other ways of calculating the price could be imagined: not only could other expenses be included, but also the unit of bone could be different. Rather than counting the number of femoral heads, the quality and weight of bones could go into the price, which would be relevant if price is to reflect demand. In fact, quality and weight considerations have gone into the bone collecting practices in some units but without affecting the price. At two hospitals, for example, knees used to be collected, too, but it was found that, considering the limited weight and size of the bone, the cost of testing was too high. At another hospital, it was decided not to collect femoral heads from donors weighing less than 45 kg as their bones would be too small to warrant the effort of testing. However, such considerations are not made in the idiom of market value or profitability. It is essentially a different type of exchange system. In the following, I expand upon the languages used to describe bone transfers, beginning with patients and bone bankers, to further unfold the form of the exchange system for this almost-human object.
Languages of bone transfers
Donors state clearly that they are not interested in receiving money for the bone they donate. Inquiring why this is the case, one man explained: ‘Well, I’ve asked to be rid of it and so on, I’ve had an improvement, so it would feel ridiculous [walking off with money]’. Another man explained that though he would not personally like to receive any money, he would not care if the bone bank sold the bone to somebody else as long as the national health services took care of the trade. Others found all commercial transfers worrisome, and compared it with ‘organ trade’. Both donors and recipients recounted with disgust stories about people in low-income countries selling their kidneys. However, some added that it could be necessary to compensate a hospital for its expenses and thus to transfer money in exchange for bone. For example, one woman said: ‘as long as it doesn’t turn into a business plan—so that they pinch something I might have needed anyway’. Therefore, in such situations, compensation for expenses would be in place, but not profit. Again the notion of compensation as clearly distinguishable from profit came forth. Still, the image of the public authorities ‘all drawing from the same account’ was typically referred to as a reason for not thinking about money at all. Apparently, parts of human bodies are, from the perspective of the people donating and receiving them, not supposed to be transferred because of money; nevertheless, economic aspects of the transfer must be dealt with, but preferably in ways not influencing the motivation of donor, recipient or surgeon. If this is so, it implies we might better understand what produces the moral ideal identified in the beginning; what it means to people. The moral ideal can be seen as related to mechanisms and everyday concerns about motives and why bone is collected, rather than abstractly related to the categorization of ‘human body part’ versus ‘commodity’.
If donors generally talk about one bone, my bone, or the bone, indicating a specific unit of bone, surgeons and bone bankers tend to use the generic term bone without an article. In general, the language used among surgeons and bone bankers is much closer to what would be expected in a business dealing with unequivocally non-human materials. The common lingo is to talk about procurement from donors as harvesting, and the subsequent transfers via the bone bank as buying and selling. These expressions were used freely in interviews; however, I did not hear this terminology used in front of patients. Bone bankers also talked about who produces or delivers, and who consumes bone, using what can be compared to farming or perhaps manufacturing terminology. Nevertheless, when looking more closely at the way bone bankers reason about the transfers, it is obvious that ‘buying and selling’ in this field operates very differently from what adherents to the ideology of the free market would expect, as already indicated in relation to the setting of a price. When talking about selling to others it was actually often referred to as ‘helping’ others. Consider the words of this bone banker, for example:
This thing about prices, it’s just kind of operational prices when it’s kind of public it’s nothing but what it costs to sort of having made sure that the bone is alright and screened and that kind of thing. So in that way you help one another. (emphasis added)
Several bone bankers complained that, because of the new EU Tissues and Cells Directive they could no longer ‘help’ the hospitals they used to—which is of course ironic for a Directive ostensibly aimed at enhancing exchange to ensure a stable supply. What should facilitate smooth exchange introduces unwanted bureaucratic impediments:
Before the new law, we did sell to private clinics too. But that stopped.
How come?
It is because … I think it’s too much bother.
Similarly another bone-bank manager thought it used to be easier:
[I]t’s a problem that we are not authorized to distribute bone. Previously, prior to this new rule, you’d be a gentleman and look in the freezer. If there was a slight surplus you would let them have some. But now we’re not allowed to, because you have to be authorized.
Reference to the gentlemanly attitude demonstrates the endurance of a public sector ethos in which bone transfers are conceptualized as a matter of helping. For some of these bone bankers the gentlemanly days are gone; but that does not imply that the new system is more business-like. It is closer to a bureaucracy. Nonetheless, most bone banks try to comply with the rules and continue to ‘help’ each other by ‘selling’ for whatever price they have decided on. They rarely comment on the notion of ‘bank’ and its monetary connotations, except when surgeons distance themselves from the increased bureaucracy associated with the EU Tissues and Cells Directive, explaining that they cannot spend all their time as ‘banking executives’. A pragmatic attitude, which distances itself from monetary issues, also characterizes the ‘consuming’ surgeons. One bank located in a top specialized unit, and thus a large consumer of bone, paid very different prices depending on where the bone came from, but did not care about the differences in price:
You know what? We really don’t care that much. We pay whatever they ask. … Really, we’re in a very difficult situation. We need bone. So we don’t quibble over whether it’s 2 Kroner more or less.
The expenses related to the new safety standards coming with the transposition of the EU Tissues and Cells Directive and the associated costs are covered partly through funds granted under a Danish regulation according to which regional authorities must be compensated for assignments imposed on them by the national authorities. Most bone bankers knew these funds (known as DUT-midler) were circulating, but knew little about whether they would go to the ward or end up somewhere else. A somewhat lengthy quotation from a bone banker who was impersonating the bureaucracy surrounding the bank with various voices illustrates the thinking very well:
We haven’t seen any money yet, right? We’re just doing loads of work [laughs]—that’s hospital life for you. Then it might be, at the end of the day, you’re told ‘Oh, you’ve spent that much? How come?’ ‘Well, it’s because we’ve got this tissue law added to everything.’ ‘Well, really?!’ And then it might be that you get an extra appropriation. But guess what—it’s just a kind of monopoly money. But I know that in several regions they’ve been very tough and said ‘We won’t take care of the bone banks before we get funds for it.’ We’ve more gone towards saying ‘Well, we’d better say it’ll cost so and so, in working hours and tests and that stuff’, right, and then add it to the bill when people order bone. And then you just hope it’ll even out. (emphasis in original)
The point is that, irrespective of businesslike languages of transfer (‘price’, ‘selling’, ‘buying’), the exchange of bone reflects a range of competing logics expressed in different discourses (‘gentlemanly’, ‘helping’, ‘bureaucracy’, ‘bother’, ‘monopoly money’).
Potential, prestige and prosperity
Further understanding of the form of exchange and its potential for change, i.e. its essential plasticity, can be gained from exploring how bone bankers contemplate adaptation of new grafting technologies. Three Danish university hospitals have looked into the possibilities of expanding their repertoire by beginning to collect bone from the deceased, so-called ‘cadaver donation’. Again the reasons should be sought in the materiality of the bone. When relying on femoral heads only, there is a clear limit to the size of the grafts that can be made. If surgeons have access to bigger bones (as well as tendons) and more sophisticated machinery they can produce more specialized grafts. The cost of this machinery and the working hours going into having a 24-hour response unit to receive cadaver donors are explicitly considered; at one hospital, however, the chief surgeon anticipated a potential income too:
If we could run a bone bank that could also make structural grafts, then … I think I can say we’d be the only ones having that—in Denmark, at least. We might have some interest in that. I don’t know if you follow me in that? It would raise the profile of the ward—would even provide a bit of financing if we could … eh … sell it to others. ’Cause it’d be something you would not get for free, definitely.
When I asked this surgeon to expand on the profitability aspect, the reply was that although his own ward might gain financially, it would surely be much cheaper for the Danish health services to buy grafts abroad rather than having surgeons experimenting with manufacture in Denmark. The key motivation was prestige. Nevertheless, it shows that the sale of bone grafts is also thought of as a financial opportunity. Some would think that this surgeon had forgotten the ban on selling bone. However, in the US and elsewhere bone grafts generate a sizeable income for many university hospitals and the agencies processing and distributing them (Cheney, Reference Cheney2006); only the surplus is hidden in so-called processing fees, compensation schemes, etc. (Timmermans, Reference Timmermans2006: 243)—a model that could easily be adopted in the Danish setting. The above quotation illustrates how the surgeon similarly anticipates translating the social capital of research prestige into monetary capital. The inability to determine accurate ‘recovery costs’ is what facilitates this type of profit generation on human tissue.
Another hospital had planned to embark on cadaver donation several years earlier, but the regional authorities did not allocate the necessary start-up funds. The running costs were expected to be recovered through the grafts. The surgeon interviewed in this bone bank had looked into the prices of grafts in other countries and thought it would be possible to produce grafts at a fifth of the price abroad. This indicates that bone transfers are thought of within a framework of expenses and income generation; they are not beyond monetary calculation but neither does the field adopt anything resembling a business strategy. Curiously, none of the surgeons had ever felt the need to import such grafts.
The prosthesis
Before and after entering the body
Just like the femoral head, its metal equivalent, the prosthesis, has both use and exchange value. It is produced as a commodity and sold freely across national borders, though the selling is structured differently in different healthcare systems. In the US, there is direct-to-consumer marketing and a degree of brand awareness (Anderson et al., Reference Anderson, Neary and Pickstone2007), while in Denmark the prosthesis is chosen by the surgeon. Mostly, prostheses are covered by a perforated titanium layer to increase the induction capacity of the patient’s own bone (Agrawal, Reference Agrawal1998). After it has been fitted, a prosthesis cannot be used again in somebody else, but in principle the titanium makes it profitable to recycle the metal. The prosthesis can be disentangled from the body again upon cremation, or in case of replacement surgery. The metal does not melt at the 900–1100 degrees Celsius used for cremating a corpse. The material’s endurance at high temperatures makes the prosthesis a problem in need of handling: the crematoria need to do something with the metal pieces lying in the ashes.
In the 1990s a surgeon and a metal expert from the Netherlands decided to begin collecting used prostheses from crematoria. Since 2000 this Dutch company has also been working in Denmark. One surgeon at a university hospital performing many hip revisions (during which the old prosthesis must be disposed of) had heard about this and he had looked into the opportunities of selling the used prostheses removed in conjunction with replacement surgery. However:
Nobody bothers to collect that crap and sell it. I’ve actually once tried to arrange it—we thought that the staff on the surgery ward could have a Christmas party [laughs] or something, if we collected them. But it turned out the price was so low that nobody bothered.
It appears that money generated from the collection of used prosthetic devices was expected to circulate somehow outside the normal hospital economy; as pocket money for the staff but not as income for the hospital. None of the hospital wards collected used prostheses. It might be because the price was too low, as suggested above. Another reason, I suggest, could be that an existing waste disposal system had already taken on this task.
Crematoria are not paid any better than hospitals for used prostheses; however, they do face the problem of waste disposal, not least because the number of implants has been increasing during past decades.Footnote 5 The material agency of the prosthesis poses a particular problem for crematoria: it can break the urn. In Denmark, where the Dutch company, with satisfaction, reports a high cremation rate of 70 percent, it is common to use degradable urns, ideally to achieve total decomposition. It is ‘to ensure that nothing reappears’, as a crematorium manager explained. This implies that crematoria wish to avoid placing metal in the urn and then having to remove it from the burial plot 20 years later when a new urn goes into the same place. The various crematoria have tried out different disposal solutions, and one simply sent the prostheses to a public dump, a ‘solution’ that was publicly criticized. Therefore the crematoria association had good reason to establish a formal collection system and the services of the Dutch company were convenient. They offered to set up bins for the metal parts and to come by and collect them on a regular basis—besides paying a price for it!
Selling the almost-human metal
In Denmark crematoria are run by local church councils on a not-for-profit basis according to the rules laid out by the Ministry of Ecclesiastical Affairs. In 2001 the ministry issued a circular stating that the gold in the teeth of a corpse and the precious metals in jewellery put into the coffin belonged to the deceased and should go into the urn, while the metal contained in prostheses should be sold to the Dutch company and the money should go to the crematoria. Leaving aside this remarkable distinction between metals, I will focus on why three of the 37 Danish crematoria decided not to comply with the new rules. In an interview, one of the three crematorium managers explained that the church council had decided that it could not agree to the selling of something ‘belonging to the person’. Again the distinction between person and commodity operates and defines what can and cannot be done to some materials. The metal, which can be sold prior to functioning as a hip, cannot as easily re-enter the market after having occupied a space in the human body.
I asked the people who had recently received a prosthesis whether they thought about the prosthesis as part of their body. They mostly replied similarly to this woman: ‘Yes, it helps me, right, or I hope it does in any case.’ When then considering how she would feel about it being sold upon cremation she said: ‘Well, if it’s lying there [in the ashes] they can take it. I don’t want them to—I’d really rather not that … when I’m dead, I don’t want them to begin cutting me up [to take it out].’ Again, as with bones, the material availability of potential exchange objects influences their range of legitimate travel. The handling of the whole shapes the access to its parts. Some of those interviewed asked questions about who received the money from the sale of used prostheses, but as long as the crematoria were not driven by profit then the prospects of increased efficiency, combined with the environmental benefits of recycling, outweighed the opposition to the selling of something almost human.
Here again the notion of not-for-profit plays a legitimizing role. Crematoria can be compensated for their expenses, but it is viewed as illegitimate for them to profit on metal recycling (irrespective of whether people were familiar with the law prohibiting for-profit cremation). Hence, just as it was the case with bone, the selling of (bodily) metal must somehow go into a budget without making anybody richer. How, then, is the price calculated—first for the cremation and then for the recycled prosthesis?
Price-setting in the crematorium context
How do crematoria calculate the price of a cremation when only expenses are to be compensated? Well, very differently in different crematoria. Some church councils cover all expenses with the income from church taxes, while others think that church tax payers should not pay for people who are not members of the church and they then charge a price for the cremation to have their expenses ‘compensated’. However, as in the case of the price for bone, costs can be calculated in many ways: some include fuel, working hours, rent, and others also include the upkeep of the grounds surrounding the crematorium, etc. There are no standards for the cost to be compensated. It is ‘basically a political decision made by the church council’ as a crematorium manager explained. Also, every cremation is charged at the same rate, even though the same manager remarked that to cremate a skinny person costs as much as 30 times more than an overweight person ‘who basically comes with his own fuel’. It has never been clear what goes into the calculation of ‘reasonable compensation’ of expenses.
How, then, does the metal recycling influence the price of a cremation? The crematoria association receives a single amount from the Dutch company for all the metal collected at Danish crematoria. This amount is then divided by the number of cremations each crematorium has carried out. Thereby it is not the specific prosthesis generating an income; it is the general level of activity at each crematorium. The amount is viewed as disappointingly low and the income from recycling does not affect the price of cremation: the extra money goes into the running of the crematorium as an opportunity for a little extra spending instead (in most countries where the company operates, the money is donated for humanitarian purposes). Though functioning as ‘compensation’ in a ‘not-for-profit’ economy, this type of money does generate surplus. However, and this is the key point, care is taken to make it appear different from commercial trade and this care sets the conditions for the exchange system.
The three crematoria that do not participate in this system collect the metal parts in separate bins; when the bins are full, they bury all the prostheses in a designated area in the churchyard. The metal hip is indeed in-between humanness and the commodity realm. It is too human to be sold but not human enough to follow the remains of the deceased into the urn and ruin the principle of total decomposition. The agency of the material, together with the moral ideals surrounding the objects, govern the desirability of various disposal options and the types of exchange they can enter. Interestingly, several of the people who had recently had a prosthetic operation found this practice quite ridiculous.
Conclusion
Boundary crossing takes place constantly and everywhere, but some boundaries are policed more heavily than others. The boundary towards the commodity realm is particularly well attended to, but in different ways and with different implications depending on how and when something is deemed ‘waste’ or somehow ‘human’. The status of being betwixt and between human and commodity is a feature characterizing not only bones but also metal substitutes. In this article I have tried to trace the implications of attempts to uphold a boundary between humanness and commodity objects, i.e. to look at how such attempts perform, shape and format exchanges of almost-human material. They do not stop the flow of materials in and out of bodies (indeed that is how bodies work and always have worked regardless of the exchanges we make). What the distinction does is to set in motion endless creativity in the ways people deal with the monetary aspects of such transfers.
The distinction can also be seen as central to the shaping of what is called ‘compensation’. I have demonstrated how the notion of ‘compensation of expenses’ provides legitimacy to the setting of a price where no price is supposed to be. But also that reference to ‘compensation’ can imply that it remains unexplored how the price is calculated and who gains in the process. I believe it is time to pay closer attention to notions such as ‘compensation’ and ‘recovery cost’. In this article I have taken steps towards this end and I have shown that the calculation of a price for objects that cannot be ‘sold’ but only compensated for can take very different routes. Some copy the ‘prices’ used by others, some estimate the number of tests kits used, others add working hours for conducting tests and for time spent during surgery, etc. Similarly, in the crematoria very different things are seen as contributing to the relevant costs.
To make a fair and workable system of exchange, some would point to a need for standards, not just of the technical type issued by the EU Tissues and Cells Directive concerning safety, but also standards concerning compensation schemes. This would imply specifying what should go into setting a price when partners exchange according to a non-profit ideal. With increased international exchange of human tissue and billions of dollars changing hands on a ‘non-profit’ basis, the point would be to avoid turning a blind eye to monetary aspects and instead to handle them in more transparent and regulated ways. This lesson is also relevant for concerned observers of the American tissue industry, because control with commercial incentives for tissue recovery must be exercised at least partly through regulation of recovery costs. However, a standardization process for compensation schemes would need to acknowledge that bone transfers are organized according to several, often contradicting, logics, and that some degree of ambiguity is part of facilitating exchanges. It is not possible to arrive at the perfect calculation ensuring accurate compensation but no potential for profit. Hence, I do not wish to submit to the illusion that new standards would solve all the problems. Still, increased transparency would indeed be beneficial.
What I would like to do, however, is to make us more aware of the multiple forms of exchange in play and thus encourage more sophisticated analyses of the types of exchange involving almost-human objects. I wish to point to the effects and powers of socio-cultural and moral ideals and thus encourage more nuanced understandings of the motivation going into tissue exchanges than what is captured by the notion of greed embodied in the crude versions of neoliberal thought. When abandoning a homogeneous notion of ‘capitalist markets’, we might begin to talk about multiple capitalisms (Rajan, Reference Rajan and Rajan2006), each posing their own analytical challenges (cf. Gibson-Graham, Reference Gibson-Graham2006). This involves, of course, moving beyond the idea that a money economy is a universal equalizer (Zelizer, Reference Zelizer and Callon1998).
Also, we should abandon the idea that human–thing hybrids are new entities emerging at the research frontier. Well-established practices have been in place to handle them for years (Pfeffer, Reference Pfeffer, Brubaker, Fehily and Warwick2009), and by studying such practices we might learn important lessons about the values, dilemmas and ideals at stake when dealing with the ‘almost-human’. The hybridity of objects that are neither clearly human nor plain commodities is just as much a result of the systems trying to create distinctions as a feature of the objects in and of themselves (Brown et al., Reference Brown, Faulkner, Kent, Michael and Webster2006). If commodification is viewed as the process of making body parts tradable, I suggest turning the analytical gaze on its head and viewing the notion of ‘trade’ as an element in the process that makes a given object (otherwise designated as waste) appear human. ‘Humanness’, then, is in this case not an inert and stable quality threatened by a universal phenomenon known as the ‘market’, but a product of material entities moving back and forth between the two semantic domains: ‘personhood’ and ‘market’. Whereas commodification theorists typically see ‘markets’ as infringing on and degrading humanness; the analytical perspective I have adopted implies seeing notions of humanness and markets as co-produced in the process of establishing specific exchange systems—such as the one for the almost-human hip in Danish hospitals and crematoria. They are embedded in material practices and experienced through moral categories. Rather than focusing on the hybrid object—the ‘tradable body part’—as a problem to get rid of, in effect trying to avoid exchanges of human biological material altogether, it is more productive to try to understand how the systems in which such objects flow actually work. Given the current emphasis on the use of human biological material in innovative health technologies, it is naïve to imagine that exchanges will simply cease just because they are criticized for commodifying the body. Rather, we need more nuanced analytical input to develop fairer, better and safer systems for procurement and distribution of such material.
Acknowledgements
This study was supported by the Carlsberg Foundation and Velux Foundation. I would like to thank the interviewees and the anonymous research nurse who helped with their recruitment as well as Sophie Birk for her assistance in interviewing bone-bank managers. Kirsten Jungersen helped identify the origins of the nullius in bonis dictum. Naomi Pfeffer and Julie Kent have both been important sources of inspiration and have also been very helpful in pointing to relevant material. Thank you very much! Naomi Pfeffer, Pablo Santoro and two anonymous referees provided helpful comments on earlier drafts.
