We grow used to the commercialisation of life. As free market logic has been boldly extended into areas of social practice where no profit making business has gone before, we have grown accustomed to the creeping commodification of public services and of common goods. But by itself, the existence of such processes is no indication of their ethical defensibility. And most of us, whatever our political commitments, support some restrictions as to the spheres in which the commodity relation might acceptably take hold. Many would draw the line either at, or near, the human body itself. For to “commodify”, in the relevant ethical sense, is to treat as a commodity something which should not be marketed. Whatever else can legitimately be bought or sold, aspects of our own embodied selves mark, for many, a step beyond the limit.

However this principle, where held, is often diluted in discussion of specific instances. Prostitution, commercial surrogacy, pornography—all of these represent ways in which the body might be commodified. In each case there are lines of resistance to the idea that commodification represents a harm in itself. A recent contribution to this journal rejects the idea that there is an in-principle objection to a market in living human organs.¹ In an oft cited article, Janet Radcliffe Richards has suggested that widespread “repugnance” concerning the idea of organ sale distracts us from more rational consideration of the issues at stake and that, on closer inspection, this repugnance has no moral or rational grounding.² As the potential for commodification has become more widespread, there has been a mushrooming of arguments of a similar flavour.

In common, their aim is to show that the selling of bodies and their parts, if wrong, is contingently rather than intrinsically so: it depends on the circumstances involved, and on the ways in which the individuals concerned are otherwise treated. Given that, in each of the case mentioned, demand currently outstrips supply, the evidence (so it is argued) points in favour of a properly regulated, individual autonomy respecting market—whether this be in organs, babies, depictions of sex, or sex itself.³

Into this thicket of issues steps Stephen Wilkinson, with this consistently thoughtful and thought provoking new book. He has produced an instructive, resourceful overview of controversies around the very idea of a trade in human bodies, their capacities, and constituent parts. Clear and accessible without compromising the complexity of the issues at stake, it merits a central place not only on specialist courses in medical ethics, but also on a far wider range besides. The great merit of Wilkinson’s approach is that it sets out, patiently and imaginatively, to unpack core concepts at work in these debates in a way that will shed light for seasoned participants as well as non-specialists. It plugs a gap in the literature, but more than that, it provides a valuable “road map” for an area of applied ethics which has not, so far, received such comprehensive, book length treatment.

The book falls into two parts. In the first part, Wilkinson explores a series of core themes on the conceptual side of “commodification” debates: “exploitation”, “objectification”, “harm”, “consent”, and “coercion”. Working on the hunch that these notions—most especially “exploitation”, which he places at the top of the “league table” of concepts relevant to commercial treatments of the body—tend to be employed without their implications being elucidated or teased out; he attempts precisely this task. It is a very helpful, largely successful project. Using relevant literature where necessary (Martha Nussbaum’s exploration of what it is to “objectify” plays a particularly useful role), Wilkinson weaves in a series of scenarios and thought experiments which help draw out nuances and tensions in the ways in which these concepts are invoked. He also shows how they interrelate: for example, how exploitation, as such, is a harm, and how if things appear otherwise in a given case, then this is because we are going by an insufficiently broad and flexible notion of harm.

Clear and accessible without compromising the complexity of the issues at stake

“Consent” rather sticks out in this company, because rather than being a wrong, it is (for many) a precondition of an act not being unduly exploitative, or coercive. However, because its conceptual role is so crucial in typical understandings of exploitation, coercion, and harm, Wilkinson places it at the heart of commodification debate. Neither does it always work simply as a corrective or counterbalance to other wrongs, so that the existence of valid consent would by itself render a practice harmless. For as he points out, some form of minimal consent is required for a practice to be exploitative—otherwise, it would not be exploitation, but theft. A mugging is non-consensual; sweatshop labour is not. Hence the slipperiness of “consent” as a notion: it both enables exploitation as well as, many would say, providing a bulwark against it. Wilkinson goes along with this line: exploitation, by its nature, involves a consent which is in some measure defective. This is a particularly fertile aspect of the book’s analysis, and might have merited more space.

The second part of the book gets more practical, singling out the trade in bodily organs, commercial surrogacy, and the patenting of DNA as areas in which the threat of possible exploitation looms large. Again, the discussions here are rich, inventive, meticulous, and illuminating (although an extra, synoptic chapter would have been helpful as a means of summarising the cases made throughout). In each case, Wilkinson takes seriously arguments both for and against legal prohibition, and identifies key overarching questions: What ethical issues are raised here? How convincing are the prominent arguments put forward in response to them? One of the strengths of his analysis as a whole is its even handedness in this respect, making it an ideal introductory text. However in a curious kind of way, this very equanimity seems to constrain the book’s conclusions, so that they are not as “conclusive” as they may seem.

To elaborate: discussing each of his three chosen practices, Wilkinson argues that sensible regulation, rather than outright prohibition, is the appropriate response to the substantial moral concerns at stake in each. He takes care to dig beneath hyperbolic or “kneejerk” dismissals of the defensibility of “selling bodies” in each respective sense—and indeed, to clarify whether these are indeed cases where the body or an aspect of it can rightfully be described as being “up for sale”. However, at crucial points questions of deeper or wider scope are avoided—sometimes with acknowledgement and sometimes not. An understandable, if significant omission is the “metaphysical” question of the relation of body to self. For good or ill, applied ethics tends not to broach such questions for fear of never leaving the starting blocks in getting to grips with practical issues. Yet meanwhile, on another tack, the issue is raised (pp 128–9) of whether a rich, Western purchaser of an organ from a desperately poor vendor in the developing world is in any way responsible for the latter’s poverty.

Now the case against an organs market tends to centre precisely on the question of who the vendors are likely to be. Those willing to sell (rather than donate) a bodily organ are, for all the obvious reasons, typically going to be poor. Any organs market would thus depend on asymmetrical power relations—and for the purposes of generating trade, the more asymmetrical the better. Wilkinson points out, fairly enough, that the questions around distributive justice thrown up by the issue he highlights lie beyond what he can deal with in any detail in his own discussion. But while such selectivity is a writer’s prerogative in charting a course through the debates, in this case it does somewhat beg the question. For it might be argued that the commodification of the body cannot be fully addressed without some attention to the wider backdrop of the “marketisation” of human interrelations, and its impact on different aspects of contemporary global life. As a moral issue, it is not an island, which brings us back to the metaphysical dimension. If, after all, it is plausible to talk of an a priori objection to the commodification of the body, the issue of why the body is not, nor should be treated as, “thing-like”, or “property”, seems to niggle. Again, not to address such relatively abstract questions in depth seems to leave a crucial gap.

Yet to criticise this book for not encompassing the broader issues above as much as it might have is, to a large extent, to criticise a badger for not being a ferret: these are niggles which it does not pretend to resolve, and are pursuable elsewhere. Wilkinson has provided the first full length, integrated study of issues which reverberate across the board of social ethics, and has addressed those issues with a rare degree of insight, originality, and awareness of the links between them. His book deserves to become staple reading for reflective practitioners in medical ethics, as well as ethicists (and this surely should be most of us) with a concern for the ever closer relations between the cash nexus and living human bodies.