The making of a moral economy: women’s views of monetary transactions in an ‘egg sharing for research’ scheme

Abstract

There are growing debates about the appropriateness of offering money in exchange for the provision of bodily materials for clinical treatment and research. The bioethics literature and many practice guidelines have generally been opposed to such entanglement, depicting the use of money as contaminating, creating undue inducement, exploitation, and commodification of the human body. However, two elements have been missing from these debates: (i) the perspectives of those people providing bodily materials when money is offered and (ii) systematic, empirical, engagement with the notion of ‘money’ itself. This article seeks to fill those gaps in knowledge by providing detailed insights from a project investigating the views and experiences of women who volunteered to provide eggs for research in exchange for reduced fees for fertility treatment. Analysis of twenty-nine semi-structured interviews reveals multiple ways in which volunteers reason through the involvement of ‘money’ in this domain and shows how their accounts diverge from pessimistic understandings of the role of monies in everyday life. When volunteers speak in detail about the monetary aspects of their participation they draw major, recurring, distinctions in five overlapping areas: their depiction of the monetized world of fertility treatment; their views of the different forms that money can take; a distancing of their actions from their understandings of how markets and commodities work; their location of the transactions within a particular clinic, and the ongoing importance of their eggs, post-transaction.

This article: (i) responds to calls for concrete case studies to assist understandings of the inter-relationships of money and specific aspects of social life; (ii) adds to the sociology of money literature by providing empirical insights into how notions of money are deployed; (iii) presents much-needed perspectives from providers of bodily materials; (iv) contributes to ongoing conversations between bioethics and sociology.

Introduction

Over recent years there have been growing debates about the appropriateness of offering money in exchange for the provision of bodily materials for clinical treatment and research (e.g. Nuffield Council on Bioethics (NCoB) 2011). References to ‘monetisation’ (Waldby et al. 2013) reflect these concerns which also resonate with wider normative discussions about the involvement of money in other transactions (Sandel 2012). The bioethics literature, and many national and EU practice guidelines, have generally been opposed to any such entanglement, depicting the use of money as contaminating and creating opportunities for the undue inducement and exploitation of providers of bodily materials and for the commodification of the human body (Haimes et al. 2012). However, at least two elements have been missing from these bioethics debates: (i) the understandings and perspectives of those people providing bodily materials when money is offered and (ii) systematic, empirical, engagement with the notion of ‘money’ itself.

In this article we seek to fill those gaps in knowledge. We provide detailed insights from interviews with women who volunteered to provide eggs for research in exchange for reduced fees for fertility treatment and deploy the growing literature on the sociology of money to gain further analytical purchase on interviewees’ complex framings of the financial features of their volunteering.

Through this analysis we seek to: (i) respond to calls, from writers as diverse as Smith (1776) and Sandel (2012), to consider concrete case studies in order to grasp the inter-relationships of money and other aspects of social life; (ii) add to the sociology of money literature by providing empirical insights into the ways in which notions of money are deployed in particular contexts in everyday life, reflecting the interests of writers such as Zelizer (1997) and Dodd (2014); (iii) complement the work of Almeling (2011) and others in showing how the association of monies and bodies is experienced by those directly involved; (iv) add to ongoing conversations between bioethics and sociology(Haimes and Williams 2007).

Background

In this section we outline the terms of the scheme in which women volunteer to provide eggs for research in exchange for reduced fertility treatment fees and explore the concerns expressed within the bioethics literature about such arrangements. We then present a brief review of the ‘sociology of money’ literature to indicate a range of possible challenges to both the bioethics characterisations of money as a social phenomenon and then, more specifically, to the entanglement of money and bodies.

Money and the human body

Concerns over the negative moral implications of the progressive monetization of social life are not new: Smith’s (1776) condemnation of usury illustrates the long standing interplay of money, markets and morality. Sandel offers the most prominent contemporary exposition of these concerns arguing that, in a society where ‘everything is up for sale’ (2012: 8), inequalities increase and important values are corroded ‘because markets don’t only allocate goods; they also express and promote certain attitudes toward the goods being exchanged.’ (2012: 9). Nowhere are these concerns more subject to critical attention than in discussions of the entanglement of money and bodies (NCoB 2011).

It is against such a backdrop that the Newcastle Egg Sharing for Research Scheme (NESR) was introduced. Under the NESR, patients going through in vitro fertilisation receive a discount of £1,500 on their private fees (approximately £3,000-£3,700) when they provide 50 per cent of their fresh eggs to clinical research. International debates about the ethics of giving women money as a strategy for overcoming the perceived shortage of eggs for research have questioned whether the money is: ‘inducement’ to provide eggs; ‘payment’ for the eggs; ‘compensation’ for undergoing the challenging procedures for producing the eggs; exploitative of patients’ vulnerability in wishing to access IVF (Haimes et al. 2012; Gupta 2011; Waldby et al 2013). The possible lexicon testifies to the social and ethical complexity of such associations.

Understanding how such schemes operate and are experienced by those providing eggs is important since other schemes have followed in the UK, such as that which recruits women from the community (that is, not IVF patients) to assist mitochondrial research and treatment; those who provide eggs receive £500 (Haimes and Taylor 2015). Questions have been raised about the effective governance of such schemes and about the positioning of individual actors within them; those designing the schemes presuppose the motivations of potential volunteers and are then praised or criticized by others who imagine similar or different motivations (Roberts and Throsby 2008; Choudhary et al 2012). For example, and unusually in international terms, the UK’s Human Fertilisation and Embryology Authority allows payments of £750 per cycle for egg donors and £35 per visit for sperm donors, explicitly to encourage donation, without ‘attracting those who are merely financially motivated’ (Pattinson 2012: 583). That ‘merely’ suggests that money is seen as contaminating even by those who find it useful under certain conditions.

The entanglement of money, markets and bodies is represented as a malign arrangement in many bioethics deliberations, where the involvement of money is seen as undermining the gifting of bodily materials and as commodifying the human body, thereby diminishing human dignity (e.g. Dickenson 2002; Baylis 2009; Widdows 2009). Such concerns have been influential in shaping EU regulations and guidelines where anxiety focuses on what is described as ‘payments’ for body parts, though there is much imprecision around what actually constitutes ‘payment’ and what any particular sum of money is for (NCoB 2011; Pattinson 2012; Haimes et al. 2012). Nonetheless, there is apparent clarity about the effects of money; as Strathern notes in relation to the donation of bodily materials, money ‘mobilizes an extraordinary range of sentiments and emotions…and has the capacity to seemingly dissolve everything into its form’ (2012: 399).

However, the bioethics notion of commodification has been criticized for being analytically inaccurate and conceptually imprecise (Appadurai 1986; Castree 2004; Parry 2008; Almeling 2011) and as based on limitations, or misunderstandings, of the ‘gift’ analysis literature which is now being rigorously challenged (Parry 2008; Elder-Vass 2015). Waldby and Mitchell, for example, draw on Callon and Appadurai to suggest that ‘things’ can travel back and forth as a gift or a commodity to being a gift again, depending on the context; this is as true of human tissue as it is of other items (2006: 25-6). Also, increasingly, scholars are challenging similar dichotomous positionings of ‘gift/market’ (Hoeyer 2013b), ‘gift/money’ (Strathern 2012) and ‘gift/sale’ (Swanson 2014).

These bioethics approaches, and the emerging challenges to them, reinforce the need to understand how those directly involved work with, and manage, money and thereby resist its apparent all-encompassing power. How do the motivations ascribed to those providing bodily materials compare with their own self avowals and reasoning? How do providers of bodily materials establish and elaborate the social and moral boundaries of acceptability around the involvement of money in what they do, when faced with apparent widespread disapproval of such transactions?

The sociology of money

Other resources, most notably the growing sociology of money, can also be deployed in challenging bioethical analyses and policy guidelines around the monies-bodies entanglements. The history of sociology has involved efforts to define and locate the topographies of money and financial transactions within its mapping of ‘market societies’. Two of the earliest and most influential of these were Marx’s critique of commodity fetishism in capitalist economies and Simmel’s phenomenology of money which addresses the cultural significance of money in modern social formations. Systematic reviews of the many studies influenced by Marx and Simmel are available from Baker and Jimerson (1992), Dodd (1994, 2014) and Deflem (2003).

In Marx’s account, relations of material production determine social institutions, within which are located typical courses of action whose patterns are reinforced through a range of ideological formations. Central to Marx’s theorising is the argument that the clue to understanding the economy of production, and the origins and nature of money, lie in the concept of ‘commodity-money’. For Marx, money is both a commodity and the medium through which commodity exchange occurs: ‘The principal difficulty in the analysis of money is surmounted as soon as it is understood that the commodity is the origin of money’ (Marx 1970[1859]: 64). However, because its possession makes possible the ownership of goods, money also represents ‘alien transactions reified in relations of exchange’, so it becomes a ‘means of domination’ as well as a ‘medium of exchange’ (Deflem 2003: 74). Other, non-Marxist, structuralist accounts downplay an over-mechanistic relationship between ‘base’ and ‘superstructure’, but maintain the primacy of the economic as a determinant of other institutional arrangements, motivations, and modes of action in which social class categories and interests, rather than individual subjectivities, are the source of agency and meaning-making. These approaches are persuasive against Adam Smith’s notions of the ‘naturalness’ of rational self interest, in which a ‘certain propensity in human nature to truck, barter and exchange’ (1776: 1) explains the persistence of market forms (Fine and Lapavitsas 2000; Birch and Tyfield 2013; Elder-Vass 2015); however, such models ‘…at best provide highly abstracted and sociologically impoverished accounts of real economic relations…’ (Barry and Slater 2002: 175).

Simmel (1978) offered a contrasting, culturalist, model for an understanding of ‘real economic relations’ by charting the effects of monetary transactions in modern societies on human consciousness and social relations. Stressing the ways in which such exchanges instantiated the anonymous and fleeting relationships of modernity, Simmel’s approach resembles that of Weber for whom the significance of money lay in its contribution to the rational calculability of modern life and to the impersonal market exchange system central to modern economic order (Deflem 2003). However, Simmel also counter-poses this by referencing money’s positive attributes, noting that the replacement of traditional relationships by market relationships facilitates an increase in independence and autonomy. Dodd writes, ‘Unlike Marx, [Simmel] refuses to predispose individuals to actions and decisions which are merely a reflection of social and economic forces over which they have virtually no control and of which they have even less understanding.’ (1994: 51). Instead, Simmel emphasizes the necessity to know the meanings which inform the uses of money.

In countering the naturalism and reductionism of many structuralist socio-economic theories, later Simmel-influenced, culturalist approaches argue that economic institutions are embedded within social relations, contexts, understandings and moral meanings (Granovetter 1985; Kaup 2015; Daly 2015). Such work draws attention to the significance of a network of institutional and personal relationships that give shape and meaning to recurrent money transactions, rather than vice versa.

Whilst there are many variations and critiques of the culturalist approach (Roscoe 2013) the broad contrast with structuralist analyses is apparent. Prominent amongst cultural theorists is Zelizer (1997) who foregrounds social meanings and interaction in her consideration of money and markets, and proposes that such ‘economic’ phenomena are shaped by the orientation of actors and agencies towards other, non-economic, factors. She argues that money-related conduct can be treated in the same way as all other meaningful actions in that their origins and consequences are necessarily found in the reasoning of actors, situated in specific social settings, within local networks of inter-personal relations. Zelizer observes that much sociological (and, more crucially for this article, we would add bioethics) analysis encourages the view that ‘money is a single, interchangeable, absolutely impersonal instrument’ that replaces ‘personal bonds with calculative instrumental ties’ and corrupts ‘cultural meanings with materialist concerns’ (1997: 1-2). Money is assumed to have the power to transform other values but there is little consideration of how money itself might be shaped by moral values or social relations (1997: 11-2). She argues instead for a more textured engagement with how money is perceived, shaped and changed by the numerous social relationships in which it plays a part (1997: 4). That Zelizer’s work has provoked further critical debate (Fine and Lapavitsas 2000; Ingham 1998, 2001, 2006; Dodd 2014) is an indication of the fruitfulness of this area of work for further sociological analysis.

Sociology, money and bodies

The above literature informs two broadly contrasting sets of critiques of the bioethics orientation to the entanglement of money and bodies. The first set of critiques reflects a structuralist orientation, stipulating the existence of, and seeking to uncover the mechanisms behind, the ‘bioeconomy’ as a resource for the analysis of this entanglement. Such an approach highlights the often naïve and limited understandings of money in much bioethics literature. An interest in the political economy of human tissue has drawn attention to the much-neglected ‘clinical labour’ of those providing tissue and body parts (Cooper and Waldby 2014). However, this approach tends to import prevailing rationalist and reductionist economic framings of money and monetary transactions into their analyses and lacks empirical engagement with those actually providing the clinical labour; actors’ understandings tend to be discounted as mere rhetorical cloaks disguising market realities (for example, Spar 2006: xi). Lately, the notion of the ‘bio-economy’ has itself attracted critical attention (Birch and Tyfield 2013; Goven and Pavone 2015).

Another, broadly culturalist, set of critiques argues that the best way to identify, access and understand the embeddedness of the economic is to conduct empirical investigations of groups, individuals or communities engaged in financial transactions. Almeling’s study (2009, 2011) of the paid provision of sperm and eggs for the treatment of infertile couples in the USA is an excellent example. Just as Castree argues for the need to chart the differing social processes through which a variety of ‘non-saleable and non-exchangeable things become saleable or exchangeable’ (2004: 25), Almeling argues that assertions about the relationship between money and body parts ‘need to be informed by empirical investigations into what actually happens when people are paid for parts of their bodies.’ (2009: 58). One prominent institutional expression of a more culturalist approach is the NCoB report, ‘Human Bodies: donation for medicine and research’ which debated how far ‘society’ should go in encouraging donations of bodily material to benefit others. In an unusual departure from most bioethics literature, the report argues that offers of money are not unproblematically ‘good’ or ‘bad’ but rather derive their meaning and significance from the contexts in which they feature; ‘each exchange needs to be viewed and evaluated independently’ (NCoB 2011: 155).

Comment

A striking feature of much of the structuralist work described above is its willingness to ‘operate with too much cognitive and normative certainty’ (Castree 2004: 24), even though the same literature shows that the meanings of key terms, such as ‘markets’, ‘money’ and even ‘bodies’, are neither fixed nor stable. Assertions about the nature of these entities are theoretical stipulations that remain in unknown relationship to the ways in which social actors actually use these and other, related, categories. In this article we therefore prefer to focus instead on trying to understand what the uses of such categories achieve within concrete exchanges. We support Dodd’s claim that ‘Individual transacting strategies must be the subject of empirical enquiry for monetary analysis in sociology…’ (1994: 78). Through the analysis of interviews with actors who are directly involved in providing human material, and taking money, within a particular set of circumstances, we seek to understand the ways in which human agency shapes the meanings and substance of monetary exchange (Hoeyer 2013a). We aim to describe the conceptual and practical resources that volunteers deploy in aligning themselves to the NESR’s monetary aspects, in dealing with the tensions and boundary challenges that arise, and in explaining their situated decisions and actions.

Money and Eggs: Shaping Meanings and Substance within Local Settings

The NESR has been described as a ‘win-win’ arrangement by the clinician-researchers because it increases the supply of eggs for research and increases access to expensive treatment for the volunteers (Choudhary et al. 2012). Others are less sure of the benefits for volunteers because the scheme requires women to provide ‘fresh’ eggs whose usefulness for their own treatment therefore remains unknown; women, it is argued, are being ‘paid to share’ their eggs (Roberts and Throsby 2008:159).

The central question for our study was: ‘does egg sharing for clinical research, in exchange for reduced IVF fees, entail social and ethical costs for those coming forward to participate in the scheme?’. This was an interview-based, inductive study, deploying a deliberately broad question to maximise the opportunities to understand the scheme from the perspectives of the volunteers themselves. We approached all 246 women who had volunteered for the NESR, achieving 29 semi-structured qualitative interviews (26 with women alone; 3 where partners also participated). All interviews were conducted by the lead author, enabling ongoing analysis and progressive focusing. The initial aide-memoir covered: demographic details; fertility history; experiences and evaluations of the NESR; views on broader debates on providing and acquiring eggs for research, and reflections on volunteering experiences. However, the interviewees shaped the discussions, introducing topics and terminology relevant to their experiences. Twenty-nine in-depth interviews, most lasting 60-90 minutes, provided more than sufficient data to reach thematic saturation. All interviews were fully transcribed.

We conducted a hermeneutic analysis of the transcripts, using constant comparison and category-building procedures followed by category mapping to identify major patterns and relationships between themes in the data (Silverman 2001). The lead author and the research assistant independently compiled lists of major themes which were then systematically compared and refined; initial coding of randomly selected transcripts led to further refinement of major themes; an agreed list of nineteen themes was then used to code all the transcripts and identify data extracts. These analytical strategies and procedures were discussed with the independent Project Advisory Group. Category mapping resulted in the emergence of five particularly prominent themes: interviewees’ fertility stories; the terms of the NESR scheme; interviewees’ egg sharing stories; the juggling of multiple considerations in deciding whether to provide eggs, and ‘money’. The emergence of ‘money’ as a central theme was unexpected; clearly the discount was expected to feature in interviews but the prominence and pervasiveness of mentions about ‘money’ more generally served to link many other themes in the analysis. This theme, like all others, was then further interrogated by the constant comparison method and the resulting sub-themes that emerged are represented by the data extracts presented here.

Earlier papers from this study have addressed bioethics characterisations of the (usually contaminating) influence of the NESR discount, such as exploitation, commodification and inducement (Haimes et al. 2012; Haimes 2013) but here our focus is on interviewees’ characterisations of the discount and how those are located and understood with reference to the myriad other ways in which money features in their accounts of participation in the NESR. The theme of ‘money’ covered many wide-ranging areas. Frequent comments were made by all interviewees about the expense of IVF treatment and its limited availability on the National Health Service (NHS) (Haimes et al. 2012). Since the eventual costs of IVF can rarely be specified in advance because treatment regimes, including the drugs required, are unique to individuals, interviewees spoke of endless calculations and of balancing priorities; for example, saving for a mortgage deposit against having more IVF; giving up holidays or selling possessions to raise funds to pay for IVF. All interviewees reported numerous other costs, including fares, petrol, car parking, snacks, overnight accommodation, childcare, interest on loans taken out to pay for IVF. Such costs could be incurred while income was lost through time off work to attend the clinic. Several interviewees referred to an ‘IVF fund’ they had built up to pay for treatment, an example of Zelizer’s ‘earmarking’ (1997: 18), indicating the non-fungibility of money and how it is accorded different significance in relation to the context in which it is discussed.

Money also featured in the construction of an IVF stereotype: ‘I didn’t want to be one of those couples who re-mortgage their house…just bankrupting themselves to have a baby’ (M17: 350-76). The reference to money expresses both the intensity of the wish for a baby and the perceived unreliability of that ‘desperation’, echoing Zelizer’s observation that a common cultural expression around money invokes its ‘shocking misuse’ (1997: 18-9). References to the wider economic climate indicated the financial risks of having IVF; debt was referred to as a normal state by one interviewee who ‘afforded’ IVF by using her credit card (M07: 557-618). The threat of unemployment magnified the risks entailed as well as the unlikelihood of acquiring credit in the first place. Frequent references were made to family assistance with fees, suggesting ways in which money is embedded within families and emotions, rather than overriding those social relationships. One interviewee’s husband illustrated the interplay of IVF costs, family assistance and the need to maintain income levels:

…there just came a time when we couldn’t [afford Partner not to work]…we borrowed the money off my mother…but we were losing money every month so borrowing it was not a great idea financially…so that was half the reason for thinking [about egg sharing] (M10: 261-79)

Financial costs of IVF, as well as the more frequently discussed emotional costs, prey on couples’ minds. Bioethics analyses imply that schemes like the NESR constitute an inappropriate introduction of money into the clinic; however, all interviewees indicate that money features heavily in the patient’s imaginary from the time that IVF first becomes a possibility. ‘Money is the thing with IVF, that’s what it boils down to’ (M21: 344-57). The ‘monetized’ world of IVF means that interviewees see the NESR discount as a way of accessing any, or more, treatment and as a way of juggling their money in relation to other factors (Haimes 2013). ‘It was a chance for us. We had a lot of eggs we could share and we could put [the discount] away for a future IVF’ (M02: 867-95). Even so, most interviewees were embarrassed discussing money: ‘…it sounds awful…we just saw “half price treatment” (laughs)…it was going to be a means to an end and hopefully half price’ (M05: 400-10)

Interviewees were all aware of commonly-available cultural framings for their participation in the NESR, such as ‘selling eggs’, but most considered this inappropriate:

It’s not for profit…it’s not about the money. The money helps…but for me it’s more about if I can help somebody else and help myself at the same time… It’s not about the cash, it’s about…being able to afford another cycle of treatment…[It’s] your means to an end that is hopefully pregnancy (M19: 906-78).

Another couple reasoned: ‘I’ve never really thought…“I’m getting paid for my eggs”…I don’t think “we’ve paid £1,500 for a baby”’ (M01: 1149-90; 1652-65)

Interviewees commonly associated ‘selling’ with ‘cash’, ‘profit’ and ‘doing it for the money’, whereas their motivation was very different. One used a range of phrases to describe the important aspects of the experience of providing eggs: ‘it was done in such a professional, reassuring, nice way’; ‘the convenience of it all being included in my treatment’; ‘not having to see anybody anywhere else, it was all done at the same clinic’; ‘you don’t get any extra stress’. These features were valuable, since, ‘My goal was just getting pregnant and having a baby… [not] thinking “oh I can get some money if I do it this way”’ (M06: 1191-258). While such convenience could reduce the critical thought given to participation, most interviewees considered it an advantage compared to seeking cash for their eggs and then paying for IVF with the proceeds. Since the discount has to be used for treatment, rather than taken as cash and used for a ‘shopping spree’, it was deemed morally acceptable: ‘It’s the only way I can explain it…’ (M27: 1619-711).

A minority of interviewees accepted the ‘selling’ label simply because money was involved but then tended to give detailed justifications, derived from the context in which the transaction occurs:

It does sound like [egg selling]. Well, it is, really, isn’t it, because they’re giving you the money for the other half of your treatment…but it’s to a good cause… I wouldn’t go on the internet and sell them but I was up for doing the egg sharing because it was the NHS who are involved in the [clinic] where I had already been and I knew it was a professional place (M18: 1041-57).

The internet as the medium through which eggs could be advertised and sold provoked particular concerns. Echoing a reference to an open market for eggs being like a ‘cattle market’ (M01: 1192-229), another woman thought selling eggs on the internet would be like selling to ‘back street butchers’ (M27: 1523-85). Accompanying this distaste was widespread uncertainty about how a market for eggs would operate:

I could say I want to sell my eggs on the internet and somebody could say they want to buy them, but how do they get them out, how do you know how many they’re taking, are you going to sit in a lab and count them together to cash up your money? … I think that sounds a little bit more seedy [compared to] somewhere where you expect the nurses to know what they’re talking about [and] the doctors to have done this before…not just wandering into a clinic to give away eggs and wander out again with a pocket full of money…! {laughs} …I would be more reassured knowing that, if I agreed to give up half my eggs, they would go for stem cell research…I’d be happier with that than giving up however many eggs for however much an egg and not knowing what would happen.’ (M28: 1233-318).

All interviewees rejected alternative ways of organizing the NESR, such as a fixed sum of money for each egg: ‘I think that would cause more anxiety…one of the things when you go through IVF is hoping you have enough eggs…if you’ve only got five eggs and you’ve already financially agreed to give away four eggs, then what’s it leave you with? …it would be more pressure’ (M23: 746-74). Fairness was a major consideration, given what women were being asked to give or ‘sacrifice’ (M07: 712-47).

…you could argue both ways cos you’re significantly reducing somebody with 50 [eggs] but then if somebody only has four and they’re prepared to give two up… aren’t they as precious as each other? … What’s ethical, what’s moral really? …every [egg] is needed when you’re at that stage so if anybody is prepared to give 50 per cent up, I think [the discount] should be equal (M25: 770-802).

it wouldn’t be fair on the person who wasn’t producing as many eggs…because obviously one egg to them is precious… (M02:846-62)

These comments highlight the lack of control women experience over the number of eggs they produce as well as their collective concern for other women in the same position. The ‘money per egg’ suggestion was not objected to because that would be more like buying (as the NCoB 2011 defines it) or selling, but on the practical grounds of reducing IVF stress and on the moral grounds of fairness.

Fairness also featured in most interviewees’ calculations of the adequacy of the discount:

I don’t think I would have done it for £100… I think the money that was given was fair, I don’t think I would have done it for less than a £1,000. In view of the pros and cons I would have weighed up… I think it was fair.

She elaborated,

I think {pause} even though… I’ve got an excess of eggs…actually donating a part of you, your own body, to research, you have to weigh it up… I wouldn’t have done it for £750, it would have been easier to just find the £750 myself… (M03: 850-83).

The adequacy of the discount could only be calculated by reference to the IVF fees: ‘…it’s not all about the money. But £100, what difference is that going to make…to me or anybody else doing IVF? What help is that?’ (M02: 779-806).

‘…it’s not how much it actually costs but [that] they were splitting the cost in half…if they said, “[IVF is] £3,000 but you can have it for £700”, I’d be thinking straightaway that’s four goes’ (M10: 1418-61).

In brief, all interviewees experience the monetized world of IVF as challenging their everyday finances, and view the NESR as an opportunity to negotiate their way around those barriers. NESR volunteers give eggs to research and consider reduced fees as a reasonable return, but they do not want payment per se, they actually want treatment, exemplifying Almeling’s (2011) point that ‘money’ does not always equal ‘payment’. It is important to grasp interviewees’ nuanced views of the role that money plays in their transactions with the clinic, rather than assume that money is the dominant factor in their decision making or indeed the dominant ethical issue from their perspective.

Our aim here has been to illustrate how everyday actors imbue money and monetized transactions with a variety of meanings that go beyond, and question, the notion of money as a single phenomenon that drives a number of other social interactions in predictable and alienating ways. Zelizer notes the ‘remarkably various ways in which people identify, classify, organize, use, segregate, manufacture, design, store, and even decorate monies as they cope with their multiple social relations.’ (1997: 1). Interviews with NESR volunteers illustrate Zelizer’s comment and indicate how a culturalist / interactionist-based approach to analysing the ways in which money features in people’s accounts tells us about both the contexts of those accounts and about the social identity of money.

Discussion

Money, as a discount to the cost of treatment, is a significant feature of the NESR scheme. The two sociological questions we ask about this are: what meanings are given by scheme participants to this particular instance of monetized exchange and how do those meanings relate to what is commonly assumed about the significance of such transactions in contemporary society? It is clear that interviewees were aware of commonplace, negative, assertions of what money ‘must mean’ in such a transaction and also what this meaning implies for their moral character. While they acknowledge the potential criticism of ‘selling eggs for gain’ and, through pauses, hesitations and jokes, express some uncertainty about how their views might be heard, they nonetheless demonstrate the heterogeneous ways in which they give money meaning in this particular aspect of their everyday lives. Their local understandings resonate with Zelizer’s (1997) and Almeling’s (2011) analyses: there is variation, nuance and complexity amongst the ways that money is represented and accommodated into their everyday circumstances and ‘distinction and multiplication appear on every hand’ (Zelizer 1997: 4).

These distinctions are apparent in five overlapping themes that can be seen to recur when interviewees speak in detail about the monetary aspects of their participation in the NESR.

(i). Constituting the IVF context

We have argued elsewhere (e.g. Haimes et al. 2012) that the particularities of the IVF context are both reflected in, and a resource for, how interviewees make sense of the relationship between monetary exchange and their own embodied identities. They do this by stressing that their identity is that of an IVF patient who is being treated in order to improve their chances of conceiving. This allows them to comment on poor NHS funding of sub-fertility treatment, as well as on the high charges made for private treatment. Participation in the NESR is characterized as one of the ways in which individuals are able to navigate this landscape; participation is not ‘about’ the money but ‘about’ getting treatment, becoming pregnant and having a baby. When interviewees characterize the monetary aspects of their participation, they show concern for others with the same goals, and for procedural fairness, rather than maximising personal monetary gain. These other-oriented concerns are a long way from the pessimistic characterizations by Weber, Simmel and Sandel of monetary transactions as ‘impersonal’ or ‘heartless’. Instead, interviewees reflect Almeling’s (2011) observations of the ineradicable embeddedness of money in specific socio-cultural contexts and the ways that actions in such contexts enable, and limit, what money is and what money does.

(ii). Configuring money

Interviewees were keen to show that NESR money is not the same kind of money that is spent or earned when goods are bought and sold; it is not ‘cash’, ‘profit’, ‘disposable income’, ‘earnings’, or ‘money back’. As a discount, it is money already ‘earmarked’ (Zelizer 1997) to provide a designated route to further IVF treatment. Almeling (2011) argues that how money changes hands is significant for how those involved experience and designate the nature of the transaction. In the NESR no cash or cheques actually change hands; while cash might produce certain consequences (women ‘doing it for the money’) a discount on the final bill cannot have this effect. These distinctions enable interviewees to consider the NESR as morally acceptable and different from other, problematic, financial transactions. Their various ways of characterizing money resonate with the NCoB’s (2011) remarks about the multiple meanings of money, although in interviews, the variation is not a matter of theoretical speculation producing conceptually hygienic distinctions, but part of an ongoing process of everyday practical reasoning.

(iii). Markets and commodities

The fact that some interviewees say that the NESR might look like selling but did not feel like it, makes it difficult to assert that their behaviour is determined by market considerations. They reject an orientation to profit and instead reaffirm a pragmatic commitment to the NESR as a way of helping themselves and others: the impersonality of market relations and conduct was replaced by a personalization of desire and commitment to assist known clinicians with research while enhancing the achievement of their own goals of conception. The meaning and value of the eggs which these participants produced and shared were determined by the extent to which their involvement in the scheme increased their chances of accomplishing their reproductive ambitions.

No interviewees wanted to imagine a fair or reasonable ‘price for an egg’, let alone enter into the rationale for one set of figures over another. Interviewees switched focus from a market place discussion about whether they should try to get the most for their eggs to a discussion about the unfairness of such proposals. Barry and Slater (2002) argue that calculating a price is both a technical and an ethical practice; NESR participants described feeling uneasy or uncomfortable when trying to manage these dual tasks. Accordingly, when asked about the levels of discount that they thought most appropriate, they were unwilling to cite specific sums of money. Notions of profit or surplus were alien to the moral world they invoked when considering the array of economic and other factors potentially at play in this particular medical context: ’You may as well put yourself on eBay!’ (M01). As they laughed about these possibilities for selling their eggs, it was clear they did not endorse such imagined practices regardless of how much monetary benefit they might gain. Interviewees’ moral reservations about such ‘rational’ market behaviour were exacerbated by their depiction of the actual market places they were imagining (‘cattle markets’, ‘back street butchers’), which they considered to be damaging to their self avowals in particular and to values of human dignity in general. The notion of commoditising body parts was not something that any of them associated with their participation in the NESR, and the invocation, graphic description and rejection of various sites that managed such transactions were offered as morally unacceptable social arrangements. This is particularly striking, given that they are also forced to be consumers in the market of private IVF treatment and given the challenges they identify in meeting those costs.

(iv). Clinical particulars

In contrast to those imagined market places, interviewees’ references to ‘the clinic’, where the NESR was enacted, portray a place which accords appropriate levels of respect, dignity, integrity and autonomy to all involved. It is described as properly regulated and staffed by trusted people, attended by others in the same position as ‘ourselves’ and as an organization that facilitates egg provision for good social reasons, namely research. Such particulars constitute the positive moral framework within which money-as-discount makes its appearance and help to shape the meanings attributed to that money in this context: far from being corroded by this exchange, the social relationships of the clinic make the involvement of money possible. This supports the NCoB’s assertion (2011: 3) of the importance of organizational procedures and professional values in evaluating the ethics of different interventions to encourage the donation of human tissue and Almeling’s (2011) focus on both the organization and experience of the market. The clinic is not only a place which is defined in contrast to the mart, it is also differentiated from other, less favoured, locations such as ‘the internet’, ‘abroad’, ‘America’ and the ‘third world’ in which issues of money and eggs become (even temporarily) interwoven.

These features reassure all parties that bodily material is ‘properly given’ rather than ‘improperly taken’ (NCoB, 2011: viii). Zelizer argues that, ‘Despite its transferability, people make every effort to embed money in particular times, places, and social relations’ (1997: 18-9). The interviewees suggest that it is pre-existing personal relationships with the specific clinic, and with the idea of ‘the clinic’, that bend money into the shapes that facilitate egg provision; that is, relationships and values transform money, not vice versa.

(v). Post-transactional relevances

If NESR egg providers were acting as ‘rational actors’ in a cash nexus, they would, by definition, be indifferent to the subsequent users and uses of the commodities that they have exchanged for money. However, the opposite is true for interviewees who expressed distaste for the marketization of their eggs by foregrounding their interest in the uses that would be made of their eggs, and by whom. They are contributing to a ‘good cause’, not seeking a ‘good profit sale’. The ‘good cause’ is defined not only in terms of an eventual health outcome for unknown others, but also more locally, as support freely given to organizations that they know: their local fertility clinic and their local university. Far from being obliterated by the offer of a discount, both pre- and post-transactional relevances, and the subjective connections that are embedded in them, are actually central to the process of volunteering for the NESR.

Interviewees retained a moral interest in, and responsibility to, the eggs that they provided. They emphasized the similarity between their eggs and other body parts, and also talked of eggs as being part of their bodies and indeed part of their selves: ‘it’s like…a bit of yourself’ (M01); ‘it’s like…something from my body’ (M02). Their view of the embodiments of these biomaterials might seem to contradict suggestions made elsewhere (Haimes 2013) that the IVF process emphasizes the separability, the entification and the exchangeability of eggs. However, in this context, NESR participants clearly view embodied eggs as nonetheless detachable and exchangeable when the relevant exchange is for support to have a baby. In this way we can see that it is impossible to ascribe any single, stable definition to the material that is exchanged, let alone a single, stable financial or moral status.

Concluding Comments

This paper has focused on the experiences of a particular group of individuals through an examination of their description of participation in a set of social exchanges. These exchanges take place in particular clinical settings that draw on specialist expertise in research and treatment and are associated with larger institutions, such as the NHS and universities. The exchanges are clearly shaped by attentiveness to a range of economic, material, cultural and medical relevances, but in this paper we have described only those that are conventionally designated as ‘economic’. In particular we have examined how notions of money and markets are deployed in interviewees’ avowals of their moral and social identities and their ascriptions of the meanings of a variety of material and social transactions.

We have juxtaposed assertions from bioethics about the presumed effects of money on social relationships with a sociologically informed descriptive account of the ways that different features of money do, and do not, matter to some of those who seek to conceive under these particular circumstances. In doing so we have outlined an instance of what Barry and Slater call the ‘localized constructions of economic processes’ (2002: 181) and what for Dodd is the ‘interpretative dimension of monetary transactions’ (1994: 78). The standard features attributed to money by economists (a medium of exchange, a measurement of value and a means of storing wealth) enter the accounts given by participants in this local exchange system, but do so only as pragmatic, shifting, and contestable features, rather than as the expression of underlying verities. Interviewees also express views on the significance of the appearance of money within systems for distributing scarce medical goods but they are concerned largely to show how they manage the meanings of this appearance ‘in line with the particular webs of relations and the various transactions that unfold within these settings’ (Carruthers and Ariovich 2010: 170).

There is also an interesting contrast that emerges when interviewees’ explorations of these issues are compared to the prescriptive accounts of the effects of money and monetization which we discussed earlier. Many such prescriptive accounts deploy a range of foundational opposites as though they are ‘inscribed in the very texture of the world’ (Pottage and Mundy 2004: 8), including for example, ‘money versus gifts’; ‘altruism versus inducements’; ‘self-interest or other-interest’. Our view, based on the interviews, is that the drawing of these and other such distinctions is best understood as a series of practical accomplishments which enables interviewees to create, achieve, challenge and negotiate boundaries between acceptable and unacceptable actions around money, bodies and identities.

An appreciation of these practical accomplishments is a necessary supplement to abstract theorising about monetary exchanges in general. As Dodd asserts, money is always an ‘open site’ whose shifting meanings and multiple uses simultaneously shape, and are shaped by, a large variety of social institutions, identities and relationships (2014:295). Whilst his analysis interrogates and juxtaposes formal economic and econometric theory with work by ‘social and cultural theorists, philosophers, and literary critics’ (p7), our appreciation of this heterogeneity of meaning has arisen from the empirical examination of what ordinary language users say when they describe the meaning of money in a particular practical context; what Dodd calls ‘reinvention “from below”’ (p13). We agree with Dodd about the necessity to examine the social life of money without a prior stipulation of its essential nature or necessary effects.

Our account can also be used to enrich bioethics and policy deliberations about the nature and acceptability of the exchanges that take place between patients, tissue providers, recipients and clinical practitioners in a variety of such social arrangements. Knowledge of the practical reasoning of interviewees provides an important counterweight to the ethical, regulatory and professional polarizations that still shape much contemporary medical thought and practice (NCoB 2011; Strathern 2012). Interviewees construe the NESR as an instance of Ingham’s ‘small, closed circuits of exchange…based on interpersonal trust and confidence’ which provide ‘limited-purpose’ credit (2004: 187) whilst saving them from the losses that would otherwise have been occasioned by having to pay the non-discounted rate for the treatment. This is an example of participants using ‘special monies’ (Zelizer 1997: 2), the discount, to empower them in the management of their transactions both with therapeutic agencies and with the many other actors and organizations involved at the edges of these transactions, such as hotels providing accommodation, companies organizing public transport, garages supplying fuel, relatives minding houses and children, and employers allowing leave.

In this paper we do not deny economic externalities to individual conduct; however, we do not use the language of ‘invasion’ (Hochschild 1983) or ‘colonization’ (Habermas 1984, 1987) of intimate spheres by markets or money to overwrite what interviewees have said about their own bio-materialities, their own moral judgements, and their own sense of the situations in which they have made fateful decisions. As others have argued, in their own examinations of different local contexts (e.g. Almeling 2011; Daly 2015), the application of such general concepts to the detailed specifics of human conduct cannot do justice to the particularities of reasoned accounting that are constitutive elements in the meaningful lives of social actors. The regularization of exchange value in the Newcastle scheme confronts patient-providers as an economic externality, but it is an externality to which they give shape by drawing selectively on a range of available social and cultural meanings. As we have seen, there was much more to what they said than an endorsement of the utility of market arrangements for the distribution of scarce commodities or a tragic acceptance of their subaltern role in a system of bio-commodification. Their reflexive engagement with debates that surround schemes such as the NESR are an effective counter to both the pessimism and the narrow understandings that accompany much social and bioethics commentary on the role of monies in everyday life.