Article

Science, Technology, & Human Values

2022, Vol. 47(1) 3-28
ª The Author(s) 2021
Markets, Cultures,
and the Politics Article reuse guidelines:
sagepub.com/journals-permissions
DOI: 10.1177/0162243921991929
of Value: The Case journals.sagepub.com/home/sth

of Assisted Reproductive
Technology

Brian Salter1

Abstract
Assisted reproductive technology (ART) is a global market engaging a
variety of local moral economies where the construction of the demand–
supply relationship takes different forms through the operation of the
politics of value. This paper analyzes how the market–culture relationship
works in different settings, showing how power and resources determine
what value will, or will not, accrue from that relationship. A commodity’s
potential economic value can only be realized through the operation of
the market if its cultural status is seen to be legitimate. At the same time,
local moral economies and their associated social orders are potentially
susceptible to the destabilizing implications of new commodities. The for-
mal or informal organization of power relationships in the market–culture
interaction can enable potential value to become manifest and tangible over
time or block its path. The interaction is steered through national institu-
tional sources of cultural authority embedded in state and religion, where

1
Department of Political Economy, King’s College London, United Kingdom

Corresponding Author:
Brian Salter, Department of Political Economy, King’s College London, Bush House (North
East Wing), 30 Aldwych, London SC2 4BG, United Kingdom.
Email: [email protected]
4 Science, Technology, & Human Values 47(1)

the visible contest in the politics of value is conducted. Increasingly, that

interaction finds its expression in transnational institutions of governance
where the struggle for control of the cultural agenda reflects the global
nature of the ART market.

Keywords
markets/economies, cultures and ethnicities, politics, power, governance,
assisted reproductive technology, Global South

Introduction
As a dynamic global market, assisted reproductive technology (ART)
engages numerous moral economies that differ widely in the cultural value
and legitimation they ascribe to particular ART commodities. As a result,
the ART demand–supply relationship assumes different forms in different
cultural locales, and the economic value of local markets is a product of
these differences. Importantly, that relationship is not static. New ART
commodities emerge with novel cultural implications and fresh cultural
values that may challenge established legitimations of particular commod-
ity markets or anticipate new ones. As these changes occur in market
commodities or cultures, they require a change in the relationship between
the two domains to ensure a continued synergy between market operation
and legitimating cultural values. Importantly, such change, or its absence, is
the result of the power relationships that govern the demand–supply rela-
tionship through the rule systems prescribed by the values of the local moral
economy. And it is politics that, through the formal or informal organization
of these power relationships in the market–culture interaction, enable the
potential economic value of the market to become manifest and tangible
over time or block its path. How does the politics of value achieve this?
The character of the global ART market and its local moral economies
complicates the operation of the politics of value. The ART commodity
market is large, global, and profitable with an estimated value in 2017 of
USD 21 billion and a growth rate of 10 percent (Grand View Research
2019). Since the first baby was born through in vitro fertilization (IVF) in
1978, the number conceived by ART now exceeds four million and
approaches 0.1 percent of the world’s population (Faddy, Gosden, and
Gosden 2018). Clinical demand driven by the core social function of repro-
duction is constant and increasing. The most comprehensive global study of
Salter 5

infertility using household data from 277 demographic and reproductive

health surveys estimated that 48.5 million couples worldwide were unable
to have a child after five years (Mascarenhas et al. 2012). This is, however,
a fairly conservative definition of infertility and other studies, defining it as
the inability of a couple to conceive after one year of regular, unprotected
intercourse, suggest 70–80 million couples worldwide (Boivin et al. 2007)
and 10–15 percent of couples (McLaren 2012; See also Rutstein and
Shah 2004).
The supply side, meanwhile, is equally dynamic and regularly enhanced
by new cutting-edge health technologies. Culturally, the ART supply
embraces a variety of techniques and products that naturally activate impor-
tant values concerning the status of the physical components of the human
body involved in reproduction (gametes, embryo, womb) and the social
structures involved in reproduction (family, marriage, motherhood, father-
hood, inheritance, preferred gender of child). Inevitably, the global
distribution of moral economies provides a wide range of modes of ART
commodity legitimation closely linked to dominant forms of social power.
At the same time, the institutional authorities of state or religion in these
cultural locales may or may not intervene to support or oppose one set
of values over another, and the nature of their intervention may change
over time. The result is a global mosaic of ART markets where the politics
of value plays a central and continuous role.
In analyzing the operation of the politics of value in the ART market, the
paper adopts a comparative international approach, drawing on material
from both the Global South and the Global North to illustrate the interaction
of market and culture in contrasting geographical and institutional domains
of religious and secular values. It begins with the power relationship among
demand, supply, and culture. How is demand constructed, what is the
formative contribution of culture to this process, and how do forms of
socially embedded power act to determine the value accorded the demand?
What is the impact of culture on the ART supply? How does culture use its
power to frame that supply in ways that attribute value to some types of
supply but not to others? Second, as the demand for and supply of ART
commodities interact, what are the implications for the engagement
between the operation of the commodity economy of ART products, on the
one hand, and the moral economy of ART values, on the other? Given that
these two economies are continually evolving, what forms of institutional
authority are employed to govern both the evolution itself and the changing
relationship between the commodity and moral economies that may accom-
pany it? Finally, to what extent does the operation of the politics of value
6 Science, Technology, & Human Values 47(1)

result in the redistribution of the balance of power between commodity

markets and local cultures?

Demand, Supply, and the Politics of Value

Markets exist because cultural values give moral status and meaning to a
perceived individual need and to the commodity that is able to respond to
that need. The expression of both demand and supply is thus a function of a
cultural context, so that markets can be described as “culturally embedded”
and “an extension of culture” (Storr 2010, 204, 205). Propelling the
dynamic of the market are individual choices made within culturally accep-
table definitions of demand and supply. In this context, what is meant by
culture is the approach adopted by Geertz, for whom “Our ideas, our values,
our acts, even our emotions are . . . cultural products—products manufac-
tured, indeed, out of tendencies, capacities and dispositions with which we
are born, but manufactured nonetheless” (Geertz 1973, 50), creating mean-
ing, shaping preferences, and providing incentives in often unconscious
fashion. Importantly, culture is dynamic and constitutes “an active process
of meaning making and contestation over definition, including itself”
(Street 1993, 2). As Wright (1998, 8) observes, culture is political because
it involves the operation of power in the use and contestation of concepts,
the definition and framing of their context, the restricting of alternative
ways of thinking about them, and the ways their meanings are rendered
authoritative and durable. For Storr (2013), culture can be seen as a con-
stitution, a set of rules, within which individuals operate and interact with
one another (p. 54). That cultural power determines how a market operates
and ensures that demand “emerges as a function of a variety of social
practices and classifications, rather than as a mysterious emanation of
human needs” rendering consumption “eminently social, relational, and
active rather than private, atomic, or passive” (Appadurai 1988, 30, 31).
Reproduction is a core social practice often linked to the survival and
development of a social group. In this context, infertility, the physical
inability to conform to this social practice, comes to be defined as a problem
that a society or individual should address, and the demand for ART is
defined as the natural expression of a social need. However, local moral
worlds vary considerably in the values they bring to bear in their definition
of the problem, its acceptable mode of expression, and the solutions that can
be legitimately adopted. Islam, for example, “considers procreation to be
one of the most important pillars of society; thus, the duty of each Muslim is
to reproduce and ensure the perpetuity of his or her social group” (Inhorn
Salter 7

and Tremayne 2012, 2): a duty that is to be carried out only in the context of
marriage, family, and the kinship system, the exclusive vehicle in Islam for
procreation, lineage, and inheritance. Providing cultural authority for the
duty and its delivery are the Quran and the hadiths (the record of the words,
actions, and silent approval of Muhammad), the source of a supporting
system of religious values explaining, supporting, legitimating, and protect-
ing both the goal of procreation itself and the particular social arrangements
within which it is to be realized (Nahdi and Sulistiyowati 2017). At the
other end of the moral continuum are secular societies where reproduction
is seen not so much as a social duty but rather as an individual right. Here,
the values of consumer choice are likely to hold sway in the context of
social structures where marriage is less highly valued, certainly not obliga-
tory for procreation to take place, and the gender roles in reproduction are
also a matter of choice rather than one of social prescription (Mamo 2007).
Between these two examples are a range of value positions associated with
religions, such as Hinduism and Buddhism, where the importance of repro-
duction is recognized but where the specification of the supporting social
structures is less precise than in the case of Islam and the flexibility of
the legitimating cultural values are more evident (Sarojini, Marwah, and
Shenoi 2011; Qiao and Feng 2014). Christianity, meanwhile, offers varied
cultural guidance on both acceptable modes of reproduction and required
social frameworks, with Catholicism highly rigorous in its pronouncements
but the numerous forms of Protestantism much less categorical
(Bonaccorso 2008).
The global demand for ART solutions to infertility thus emerges in
contrasting cultural contexts that legitimize different embedded formula-
tions of social power and, through the operation of these power configura-
tions, different forms of demand. As Gurtin, Inhorn, and Tremayne (2015)
observe, “the social meanings of infertility are always the discursive prod-
uct of a hegemonic cultural system” (p. 3138), and such meanings act to
reinforce the social hierarchies, structures, and role divisions (particularly
those of gender) that define them. From this synergy is born the politics of
demand value through the application of social power to endow positive
cultural value to some types of ART demand and negative value to others.
In societies where reproduction is highly valued, social stigma reinforces
and magnifies demand through the attribution of negative social value to the
inability to reproduce. Where large families are the norm, as in Africa, for
example, the application of this negative value produces what Cui (2010)
terms “the agony of infertility.” Women “unable to bear children are
rejected by their husbands and ostracized by society, often living as outcasts
8 Science, Technology, & Human Values 47(1)

and perceived as inferior and useless” (Lunenfeld and van Steirteghem

2004, 321). Similarly, in Indonesia, infertility is stigmatized as a “curse,”
often linked to psychological crisis, social isolation, and violence (Bennett
et al. 2012). In many Muslim countries, the effect of social stigma on the
demand for ART is enhanced by the cultural proscription of a possible
alternative solution to infertility: Islamic scriptures explicitly forbid the
adoption of children. Infertile Muslim couples may foster an orphaned
child, but permanent adoption is disallowed in family law in the vast major-
ity of Muslim countries (Gurtin, Inhorn, and Tremayne 2015, 3141).
The power at work in defining and controlling demand for ART in these
kinds of cases is that of the patriarchal society, often supported by religious
values such as those of Islam. Responsibility for infertility is disproportio-
nately relegated to women, reinterpreting the objective demand produced
by clinical need in a manner concordant with the society’s structures of
social power. Involuntary childlessness can be caused by a variety of phy-
siologically male or female factors ranging from low sperm count to azoos-
permia in men, and premature ovarian failure to blocked fallopian tubes in
women. But despite the fact that male-factor infertility accounts for about
50 percent of all cases, globally most of the social responsibility for infer-
tility is imposed on women and most of the ART demand constructed in
terms of solutions to female fertility problems (Inhorn and Van Balen
2002). For men in patriarchal societies, the social stigma of infertility acts
in precisely the opposite direction to that of women, evoking notions of
impotency and emasculation to suppress the articulation of need and reduce
the ART demand from men (Inhorn 2004, 2005). In combination, these two
mechanisms of cultural power produce a highly gendered global demand for
ART technologies largely geared to the causes of female infertility with
men treated as “the second sex” in ART practices and discourses (Inhorn
et al. 2009).
The cultural translation of different types of clinical need into socially
valued forms of ART demand is sensitive to the nature of the ART com-
modity supply that can itself stimulate a cultural response and help define
the demand–supply relationship. This approach to commodities builds on
the work on commodification by feminist scholars in medical anthropology
and science and technology studies who have documented how “bodily
commodification”—namely, the packaging and selling of gametes and
other body parts for the purposes of reproduction and medical research—
has become the vehicle for a global consumer market (Kroløkke, Foss, and
Pant 2012; Scheper-Hughes 2005). In part, this emphasis on commodity
production was the result of a concern with contrasting gift economies and
Salter 9

commodification (Waldby and Mitchell 2006). Although this literature

deals with the social context in terms of the impact of commodification
on core constructs such as kinship and motherhood (Kopytoff 2004;
Kroløkke, Foss, and Sandoval 2010), it does not fully elaborate how that
context shapes, or does not shape, the emergence of legitimate commodi-
ties. As Hoeyer (2007) argues in his critique of the hypothesis of commo-
dification, “To consider commoditization as a process means to empirically
investigate the ways biogenetic substances, at various points, move in and
out of a commodity state” to enable them to travel as “products” and not as
persons (p. 329). This view accords with Birch’s approach to “assetization,”
the transformation of something into a revenue-generating and tradable
resource, where he maintains that commodification needs to be situated
in the context of “the social practices and processes of valuation in the
bio-economy, which are characterized by an active, ongoing, and perfor-
mative management of value” (Birch 2017, 462; See also Birch 2015). In
Birch’s case, the focus is on how “value is constituted primarily by the
social practices of the political economic actors who configure the financial
value and valuation of firms” (p. 462). This paper focuses on how value is
constituted through the social and cultural practices and power alignments
that govern the demand-supply relationship in the commodity economy: the
politics of value.
In the case of ART, the commodities include, but are not limited to,
intrauterine insemination (IUI), IVF and embryo transfer, intracytoplasmic
sperm injection (ICSI), gamete intrafallopian transfer, zygote intra fallopian
transfer, tubal embryo transfer, gamete and embryo cryopreservation,
oocyte and embryo donation, and gestational surrogacy. Broadly speaking,
the response is organized around a culture’s view of the status of key
elements in the physical and social processes of reproduction. For religious
cultures such as Catholicism the status of the human embryo in reproduc-
tion is absolute; for others, it is negotiable. Equally, for religious cultures
such as those of Islam the role of the family is essential, while for others it is
optional. These kinds of value positions influence or determine what forms
of demand–supply relationship are culturally valued and what not, and
therefore what kinds of ART markets can legitimately exist within their
cultural jurisdictions. Sallam and Sallam (2016) have summarized the effect
of this application of the politics of value in terms of the relationship among
a range of religious cultures and types of ART commodity in the Table 1
below (see also Gurtin, Inhorn, and Tremayne 2015: table 165.1 for a
parallel exercise on Shia and Sunni countries and secular Turkey). Although
religions clearly are not the only form of transnational cultural influence in
10
Table 1. Religious Culture and ART Commodity Relationship.

Religious Culture Art Commodity

IUI IVF/ICSI PGD Surrogacy Gamete Donation Fetal Reduction

Catholic No No No No No No
Orthodox Yes No No No No No
Protestants Yes Yes No No No No
Anglicans Yes Yes No No No No
Coptic Yes Yes Yes No No No
Judaism Yes Yes Yes Yes Yes Yes
Sunni Islam Yes Yes Yes Debating No Yes
Shia Islam Yes Yes Yes Yes Yes Yes
Hinduism Yes Yes Yes Yes Yes Yes
Buddhism Yes Yes Yes Yes Yes Yes
Japan Yes Yes Yes No Sperm only Yes
China Yes Yes Yes No No Yes
Salter 11

the ART market, they are a significant source of value reference for the
91 percent of the world’s population shaped by religious affiliation and the
often formal nature of their value articulation provides useful material for
the explication of this paper’s argument (Pew Research Centre 2015).
Each cell in this religious culture–commodity matrix constitutes a poten-
tial market where the demand–supply relationship is either culturally valued
(“Yes”) or not valued (“No”). As is discussed in the next section, the extent
to which these values are implemented and impact on the ART market is
dependent on their degree of incorporation in the institutional rule systems
of state or religion, but they provide the starting point for the analysis. As is
immediately apparent, the most comprehensive potential market restriction
is advanced by Catholicism. Here, the formal dogma of the Church asserts
that the moral status of both human embryo and family is absolute and the
physical and the social are also indissolubly joined. Pope Francis has to an
extent reframed these principles in his Amoris Laetitia (Joy of Love) (Pope
Francis 2016; which brings together the results of the two Synods on the
family convoked by Pope Francis in 2014 and 2015—US Conference of
Catholic Bishops 2015) to allow for their sympathetic and flexible inter-
pretation, but their essential message and import remains unchanged.
Regarding the embryo he asserts: “Each child has a place in God’s heart
from all eternity; once he or she is conceived, the Creator’s eternal dream
comes true. Let us pause to think of the great value of that embryo from the
moment of conception” (Pope Francis 2016, 128). And on ART he is dis-
approving of “the technological revolution in the field of human procreation
[which] has introduced the ability to manipulate the reproductive act, mak-
ing it independent of the sexual relationship between men and women. In
this way, human life and parenthood have become modular and separable
realities, subject mainly to the wishes of individuals or couples” (Pope
Francis 2016, 45) thus challenging the central role of the family.
Compare this with the position of Sunni Islam which gives marriage but
not the embryo an absolute status in reproduction: it permits IVF using eggs
from the wife and the sperm of the husband, and the transfer of the fertilized
embryos back to the uterus of the same wife. The embryo may be manipu-
lated within the social confines of a marriage but no third party should
intrude into the marital functions of sex and procreation through the dona-
tion of sperm, eggs, embryos, or a uterus (as in surrogacy; Inhorn 2008, 35).
Rather less categorical and more complex is the cultural guidance of
Shia Islam, where debate regarding the values that should govern
the demand for ARTs is vibrant and at least partly a reflection of its less
hierarchical approach to cultural authority, as discussed further below. In
12 Science, Technology, & Human Values 47(1)

Shia-dominated Iran and Lebanon, there is continuing discussion of issues

such as whether gamete donation without bodily contact truly constitutes
zina or adultery; and whether the husband of an infertile woman needs to
arrange a temporary marriage (mut’a—condoned in Shia but condemned in
Sunni Islam) with the egg donor and then release her from the marriage
immediately after the embryo transfer in order to avoid adultery (zina;
Inhorn 2007; Tremayne 2009).
Such debates illustrate the capacity of the ART supply side to challenge
not only the hegemonic discourse of a particular culture but also the social
structures which that discourse legitimizes. The politics of value then takes
on a dynamic quality as the market–culture relationship becomes politically
interactive. If fresh values and modes of cultural understanding become part
of the reproduction discourse, prompted by the opportunities to remedy
infertility offered by new technologies, assumptions regarding the delivery
of reproduction through embedded forms of social power may be ques-
tioned. In Islam, the cultural symbiosis among parenthood, marriage,
kinship, lineage, and inheritance means that revision of one element in that
sequence, such as parenthood through third-party gamete donation or
surrogacy, is likely to affect the others because the system is designed to
be rigid and strong (Inhorn 2006). Where cultural flexibility is introduced,
as in Shia Iran and Lebanon, implications arise for potential ART consu-
mers in neighboring Sunni states. With the supply of ART donor technol-
ogies now widely available in both Shia Iran and Lebanon, the power of the
Sunni Muslim ban on third-party donation is being weakened across the
Middle East, with some infertile Sunni Muslim couples prepared to reex-
amine their anti-donation moral position in order to “save their marriages”
and engage in clandestine “reproductive tourism” across state borders to
more liberal Shia regulatory regimes by means of what for them is the ART
black market (Inhorn 2008, 42; see also Inhorn 2009). This market works
across the ancient Islamic schism between Shia and Sunni, characterized by
historic rivalry between the two sects, fractious religious and political com-
petition, and periodic military confrontation. Its activities result in Sunni
culture being challenged by the ability of the ART market supply to appeal
directly to its reproduction consumers resulting in “Shia gametes finding
their way into Sunni bodies” through IVF and gamete donation despite
the severe cultural antipathy between their respective owners (Inhorn
2008, 42).
In similar fashion, but in the quite different cultural context of secular
Western societies, Strathern’s work has shown how the supply of new ART
commodities has the potential to stimulate a demand that also challenges
Salter 13

hegemonic understandings of relatedness and kinship (Strathern 1992).

ARTs and their associated access to third parties allow the “natural”
relationship between the biology of reproduction and traditional notions
of family and kinship to be ideologically reformulated, so that the nature
of parenthood is seen as a matter of consumer choice and the role of society
as facilitating that choice and perhaps ensuring the quality of the product.
The dominant norm of heterosexual parenthood and marriage is destabi-
lized when a given society accords legitimacy to the reproductive demands
from nonmarried couples, single women and men, lesbians, and gay men for
donor insemination and gestational surrogacy (Cadoret 2008). As its culture
responds to opportunities offered by ART, value is reassigned and social
power redistributed. Motherhood is deconstructed from a unified biological
and social entity into a plethora of genetic, birth, adoptive, and surrogate
maternities each with its own ART commodity, or sets of commodities,
designed to enable its realization (Thompson 1998). And in the secular
consumer society, there is no stigma attached to the transnational exercise
of choice through the global fertility market. In this cultural domain, global
reproductive tourism is presented not only as possible but also as rational,
reinforcing through its activities the normality of the cultural adjustment
made by a society and demonstrating how the commodity market can both
cause and consolidate political value (Inhorn and Patrizio 2012).

Constructing Political Value: The Institutional

Sources of Authority
The politics of value are defined by the mutual abilities of cultures to shape
the demand–supply relationship and of commodity markets to reshape the
cultural context in which they operate. Power is at work to confirm or
redistribute cultural and social values and legitimate or deny commodity
value. But what political factors help determine the balance of power
between culture and markets, given that neither cultures nor commodities
are static entities but evolving over time? Undoubtedly, local moral worlds
form part of a global moral economy where exchange is commonplace and
values traded to achieve a workable compromise, just as commodities are
traded to achieve a profitable outcome (Salter and Salter 2007). But both
moral and commodity economies conduct their activities within authority
structures that frame the rules, or choose not to frame the rules, governing
their engagement. It is here that the politics of value in the ART market may
take on institutional form.
14 Science, Technology, & Human Values 47(1)

North explains how “the institutional structure reflects the accumulated

beliefs of society over time” so that “there is an intimate relationship
between belief systems and the institutional framework,” arguing that
culture determines the direction institutions take and the rules they propa-
gate about how economic activity should be conducted (North 2005, 49).
There is, then, the question of which institutions of state and society, if any,
engage in the governance of ART? In its 2019 survey of its 107 member
states, the International Federation of Fertility Societies (IFFS) found that
64 percent of states had statutory regulation on the conduct of the ART
market (rising to 87 percent if guidelines were included) with large regu-
latory divergence between states reflecting their varied cultural identities
(IFFS 2019, 9). So local moral economies may find their cultural values
translated into institutional rule form or they may not, particularly in devel-
oping countries with limited governance capacity where informal rule
systems predominate. Even where state institutions provide rule frame-
works, these may be challenged by unresolved cultural tensions in society
and the changing balance of power between competing ART interests. In
the United States, federal regulation of ART is limited in its unifying effect,
with individual US states adopting a plethora of contrasting permissive and
restrictive measures on the ART market, each a reflection of the dominant
cultural view of the status of the human embryo within particular state
jurisdictions (Frith and Blyth 2014). ART commodities legitimized in one
state may be illegal in another. Such is the intensity of this conflicted
dimension of the politics of value that it has been described as a “culture
war” (Hunter 1994), with the institutions of religion significant players
on both sides of the cultural divide (Hoffman and Johnson 2005;
McConkey 2001; see also Mulkay 1997 on a parallel, if less intense, United
Kingdom debate).
Religious institutions vary in the extent to which they can influence the
politics of ART value through their provision of an authoritative cultural
view of the regulation of the ART market, which the institutions of the state
feel obliged to accept and implement through statutory guidance. Several
aspects of religious power are at work in this domain. Much depends on
how far organized religion has been able to maintain a relationship with the
state in the face of the increasing secularization of societies and the support
for new ART commodities that this entails. In Western states, the Catholic
Church has long fought a rearguard action against the expansion of the ART
market, particularly with regard to the majority of ART commodities where
the status of the human embryo is an issue. It has had limited success in
setting the cultural terms of the ART debate in states such as Italy, Austria,
Salter 15

and Poland where its relationship with the state is most secure (Hennig
2020; Minkenberg 2002). Allied to this is Catholicism’s ability to call on
a population’s support: Fink identified a clear relationship between the
proportion of Catholics in a European country and restrictive embryo
research policies (Fink 2005). However, this relationship does not always
hold. Instructively, in Ireland, the decline of the moral authority of the
Catholic Church and its ability to control the ART policy agenda have been
accompanied, and partly caused, by the rise of secularism as an organized
and compelling political force (Allison 2016; McDonnell and Allison 2006;
Inglis 1998). Ireland’s experience shows in microcosm, and in unusually
dramatic form, the weakening of religion’s power across Europe to act as a
source of authority for the values that should govern the ART market in the
face of secular consumerism (Salter and Salter 2007, table 2). Only in Italy,
the home of the Catholic Church where the religion–state nexus is strongest,
has national policy making moved to a more conservative position with the
implementation of the 2004 Assisted Fertility Act (Inhorn 2010).
In contrast to the Western experience, the institutional politics of ART
value in Asia has taken a quite different form. Here, the resurgence of
Islam1 demonstrates how an institutional alliance between religion and state
can support local moral economies capable of resisting or channeling the
ART demands of an expanding middle-class sensitive to the breadth of the
ART supply. And in contrast to the Western experience, in the case of
Islam, it is generally religion rather than the state that acts as the dominant
cultural authority in that relationship and so it is to institutional divergences
within that authority to which we should look for insights into how the ART
market operates in Muslim countries. Of the twenty-two Middle Eastern
nations, for example, only six countries (Algeria, Iran, Israel, Tunisia, Tur-
key, and the UAE) have enacted assisted reproduction legislation (Jones
et al. 2011). Egypt, Jordan, and Saudi Arabia—the first three Sunni Muslim
countries to open IVF clinics—have never passed assisted reproduction
legislation. Instead, as Inhorn (2008) puts it, it is the “strong religion/weak
state” reality that has led to “two clear patterns of ART practice which
follow the growing Sunni/Shia sectarian divide” (p. 34). Given that ARTs
are used to produce offspring for infertile couples, their governance within
“sharia” (Islamic religious law) comes under the aegis of Islamic family law
in both Sunni and Shia states where the ART rules promulgated through
“fatwa” (authoritative rulings by senior Islamic clerics or scholars) define
the cultural limits of acceptable ART commodity use for both clinicians
and patients. Bioethical and professional codes are backed up with sanc-
tions such as clinic closure and confiscation of profits (Gurtin, Inhorn, and
16 Science, Technology, & Human Values 47(1)

Tremayne 2015, 3143). However, while these codes are both uniform and
regularly enforced in Sunni states, the institutional character of the cultural
authority structure in Shia dominated states allows more flexibility and
choice for the ART consumer, as was mentioned earlier. Here, Shia scholars
are reluctant to engage in the formal collective deliberations based on
scriptural sources that characterize the Sunni approach and instead prefer
an individualistic practice of “ijtihad” (independent reasoning) leading to a
greater diversity of cultural authorities and opinions. In the case of
third-party donation, this had led to Shia doctors and patients in Iran having
a greater degree of agency and control over clinical practices and more
independent understandings of what constitutes kinship and relatedness
(Clarke 2007). Such discursive openness on the part of the institutions of
cultural authority in Iran is not neutral in its effects but rather socially
destabilizing to an extent, illustrating the ability of the commodity market
to impact on a society’s culture while at the same time being defined by it
(Tremayne 2012).
The institutional politics of value determines not only what values
should govern the commodity market but also how the relationship between
commodity and moral economies changes over time—new commodity
legitimations produced or old ones removed. As new ART commodities
have been generated and fresh social possibilities have been created, so
there has been a demand in moral economies for the means to govern these
possibilities either through the adaptation of existing values or the creation
of new ones. What Williams (1978) termed “emergence” has become a
feature of the ART discourse as “new meanings and values, new practices,
new relationships and kinds of relationship . . . are continually being cre-
ated” (p. 123). Such a governance demand is also a political opportunity in
the sense that an authority is required to pronounce not only on what values
should be applied to the governance of the new commodity but also, if new
or adapted values are needed, how they should be produced. To put it
another way, who should govern the production of the cultural values that
govern the commodity market? Are the existing cultural authorities within a
jurisdiction sufficiently epistemically adroit to retain their grip on its moral
economy or is there an opportunity for a new player to gain political advan-
tage through its cultural expertise?
In Western secular societies, the political opportunity has been seized by
bioethics, which, following the rapid expansion in new health technologies
in the 1970s, has become the primary institutional authority at national
and international levels for cultural reflection and decision making on the
market suitability or otherwise of these types of commodities (Jonsen
Salter 17

1998). Born of medical science’s need for new modes of legitimation for its
processes and products, bioethics has proved itself to be epistemically adroit
and politically useful in managing the tension between the market potential
of medical science and its cultural locale. Its authority derives from its claim
to be neutral and objective through its use of a supra-cultural method incor-
porating “tools for measurement that transcend culture” (Bosk 1999, 63).
Precisely what this method is and how it is applied in different Western states
has evolved and diversified over time to incorporate contributions from
disciplines ranging from moral philosophy and law, through feminism and
theology, to medical science and medical ethics (Camporesi 2017; Salter and
Jones 2005: see Tables 2 and 3). Originally conceived as an exercise in the
enunciation and application of a set of what were seen as “universal ethical
principles” (variously defined; Hedgecoe 2004, 125), bioethics sought to
establish standardized rules that could enable the translation of different
moral positions into a common metric capable of facilitating, usually on a
cost–benefit basis, choices and decisions. For this method to operate
efficiently, it had to enable a system capable of commensuration (the
discarding of information), predictability, and calculability: the characteris-
tics of a currency (Evans 2000; see also Clouser and Gert 1990). Then
through its control of “the common coin of moral discourse” (Jonsen 1998,
333), bioethics would be able to dominate the framing of the production of
governance knowledge in the Western moral economies of new health tech-
nologies and, in consequence, gain the ability to shape the activities of the
commodity markets that such moral economies deem legitimate.
To an extent, this neat equation, though true of the early stages of
bioethics development, has been challenged by its subsequent diversifica-
tion and internal competition regarding its core principles and disciplines
(Engelhardt, Iltis, and Carpenter 2012; Iltis 2016). Indeed, Franklin
has gone so far as to argue that ethical oversight in the biosciences
now belongs to a multiplicity of actors rather than being the exclusive
domain of bioethics (Franklin 2019). Nonetheless, it remains the claim of
much of bioethics that “ethics expertise cannot be improvised, and that
ethicists are better placed than non-experts, that is, they are at an ‘epistemic
advantage’, when discussing the normative questions raised by biotechnol-
ogies, biomedicine and the life sciences” (Camporesi and Cavaliere 2021,
2). Here, the claim to authority rests not on the use of particular universal
principles but rather on “the adoption of different analytical lenses [that]
can illuminate morally salient features of a case, or of a practice, which
would go unnoticed otherwise” (Camporesi 2017, 179). As a result, bioethi-
cal reflection can “help unravel some of the assumptions and value
18 Science, Technology, & Human Values 47(1)

judgments that we make in the context of some of the current practices of

externalization and responsibilization of reproduction” (Camporesi 2017,
180). The ability to dissect and organize the understanding of “value
pluralism” then endows bioethics with the right, and perhaps the duty, to
claim its “epistemic advantage” in contributing to the governance decisions
that flow from this exercise (Cavaliere 2017; see Camporesi and Cavaliere
2021). As bioethics has evolved, so the character of its political ambition
has become more nuanced.
The institutional manifestation of the bioethics mission to act as a global
moral arbiter is apparent in national bioethics committees, international
committees such as the International Bioethics Committees and the
European Group on Ethics in Science and New Technologies, and a global
network of bioethicists working through organizations such as the Council
for International Organizations of Medical Sciences (CIOMS), the Human
Genome Organization, the International Society of Bioethics, the World
Medical Association, and the World Health Organization. In Western
societies—and despite, or because of, its reflexive turn—bioethics has
enjoyed considerable success in influencing the values that should guide
the production of new health technologies in ways that enhance the capacity
of medical science to innovate and commodify (Salter and Jones 2005). In
stem cell research and development, for example, there has been a consis-
tent global shift across nation states, initiated by bioethics, toward more
permissive regulation and away from policies that constrain the develop-
ment of stem cell products due to concerns about the status of the human
embryo (Salter 2007; Salter and Salter 2007, 571-74). Rapidly gaining
political experience and expanding its influence, the bioethical enterprise
has steadily improved its skills and capacity to link “bureaucracy—
committees, institutional regulations, and finely tuned language—with
claims to moral stature” (Rosenberg 1999, 38). States wishing to engage
the health technology market routinely find themselves receiving Western
bioethical advice on the processes of normative reflection that should be
used to steer their regulatory affairs. In China, for example, the domestic
epistemic community of bioethicists engaged in lengthy debate and nego-
tiation with international bioethicists, primarily from the United States, on
the values that should govern stem cell science and innovation, eventually
producing policy guidance remarkably similar to the international consen-
sus in this domain (Salter and Qiu 2009). Propelled by bioethics, the global
moral economy asserted itself as the arbiter of inter-moral economy
relationships.
Salter 19

Not all local moral economies are so susceptible to the transnational

ambitions of Western bioethics. Islam, for example, has proved much less
pliable and much more prepared to assert its cultural power to protect what
it sees as its moral terrain and its commodity market. Here, the politics of
ART value are directly informed by competing modes of moral economy
organization and epistemic power. Like bioethics, Islam has its national
institutions and transnational networks designed to act as the vehicles for
its cultural authority. Unlike those of bioethics, these institutions are
embedded in the sociopolitical fabric of Muslim states and draw on the
established tenets and authority of the Quran and the hadiths. Any conver-
sation about the ethics of ART has to be conducted through the religious
courts and the good offices of religious leaders and scholars, a process
which may, as we have seen in the case of Shia Iran, produce a range of
opinions—but always within the confines of established Islamic principles:
“Islamic bioethics” is necessarily an extension of sharia (Chamsi-Pasha and
Albar 2015, 108. See also Alaro 2012). Also different is the epistemic
method whereby ethical conclusions are reached and a new value position
established. For a given health technology, Western bioethics applies rea-
son and empirical findings through a set of principles or the explication and
balancing of rival moral positions. In Islam, “bioethical deliberation is
inseparable from the religion itself, which emphasizes continuities between
body and mind, between the material, and spiritual realms and between
ethics and jurisprudence” (Chamsi-Pasha and Albar 2013, 9). Unsurpris-
ingly, differences of method in the evolution of moral economies produce
different results. For Islam, the value of duty to family, kinship, and com-
munity has a prior status to that of the value of individual autonomy prized
by Western bioethics and clear implications for the legitimacy of particular
ART commodities.
In the international institutional politics of ART value, Western bioethics
finds it difficult to penetrate or unravel Islam’s integrated moral economy
rooted as it is in Islam’s institutions of religion, state, and historic social
practice. The several branches of Islam are well aware of the ambition of
Western bioethics and that as a transnational moral economy Islam must
continue to develop and respond to new health technologies through the
sponsorship of international institutions and networks in order to retain its
cultural authority and control of the commodity markets of medical science
within its jurisdictions. As early as 1980, only two years after the first IVF
birth in England, and six years before the opening of Egypt’s first IVF
center, the Grand Sheikh of Egypt’s religious university, Al Azhar, issued
the first fatwa on medically assisted reproduction—one that has proved to
20 Science, Technology, & Human Values 47(1)

be authoritative and enduring in all its main points (Inhorn 2008, 34-35). In
1981, the First International Conference of Islamic Medicine was held in
Kuwait with the International Organization for Islamic Medicine (IOSM),
the primary transnational institutional vehicle for the exchange of views in
Islam on ART and other health technologies, founded in 1984. International
conferences organized by IOSM, such as the “Bioethics and human repro-
duction in the Muslim world” meeting in Cairo in 1991, brought together
Islamic scholars from numerous countries with the aim of sharing and
formulating bioethical positions (Nahdi and Sulistiyowati 2017, 84). Simi-
larly, in 1997, the IOMS conference in Casablanca produced a five-point
bioethical declaration that included recommendations to prevent human
cloning and to prohibit all situations in which a third-party compromises
a marital relationship through the donation of reproductive material (Moosa
2003). Authoritative codification of the principles that should be used to
guide the continuing debates came with the Islamic code of medical ethics
(1981) issued following the Kuwait conference and the International
Islamic code for medical and health ethics (2004) issued following the
Eighth IOSM conference in Cairo. It is important to note that the latter was
produced in collaboration with the Eastern Mediterranean Regional Office
of the World Health Organization (WHO-EMRO), the Islamic Educational,
Scientific and Cultural Organization, and the CIOMS (Al-Awadi 2004:
foreword). The political effect, and probable intent, was to link the burgeon-
ing moral economy of Islam with established and non-Muslim international
institutions tasked with facilitating global ethical discourse, thus improving
Islam’s international status, bargaining position, and ability to protect its
commodity markets.

Conclusions
As Storr (2013) has observed “Market interactions are culturally con-
structed” (p. 31). But the question is how. This paper has explored the
process of construction in the case of the global ART market by analyzing
the continuing mobilization of cultural and social power in the engagement
between commodity and moral economies. From this engagement flows a
politics of value where economic, social, and cultural values are constantly
interacting. The demand–supply relationship of the ART commodity econ-
omy is constructed, maintained, and, if necessary, adjusted through conti-
nuities or changes in the local moral economies providing the means for its
legitimation. At one point, a moral economy may have the ascendancy
through its capacity to define demand in a clear and unequivocal manner.
Salter 21

At another, changes in the supply side of the commodity economy may

cause a reflexive tremor within a moral economy and a reordering of
cultural value, modes of legitimation, and supporting social structures.
Depending on the nature of the social and institutional order, some moral
economies, such as those of Islam, are sufficiently stable to guide the
cultural impact of new ART commodities through established value chan-
nels. Others, such as the secular moral economies of the West, find them-
selves responding to new ART commodities with cultural and social
changes, often facilitated by the “impartial” contribution of bioethics.
Throughout these activities, power (and the struggle for power) shapes
and determines the allocation of economic and cultural value and confirms
or challenges the existing social order. No moral economy is politically
neutral and no commodity economy politically passive. Their interaction is
steered through national institutional sources of cultural authority
embedded in state and religion wherein the visible contest in the politics
of value is conducted. Increasingly, that interaction finds its expression in
transnational institutions of governance where the struggle for control of the
cultural agenda reflects the global nature of the ART market. Here, the
expertise and secular authority of bioethics engages with that of organized
religions, such as Islam and Catholicism, in the pursuit of cultural compet-
itive advantage in the global ART moral economy. As political actors,
cultural authorities are naturally ambitious in their pursuit of the power to
determine the value framework that guides the market, protective of those
commodity markets already within their jurisdictions, and interested in the
future governance of new commodities that may challenge the social basis
of their power. When competition between moral economies is combined
with the ability of medical science to produce new ART commodities, the
continuity and dynamism of the politics of value are assured.

Acknowledgments
The author is grateful for the comments of the two referees and for the contribution
of the editors to the integrity of the text.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research,
authorship, and/or publication of this article.

Funding
The author(s) received no financial support for the research, authorship, and/or
publication of this article.
22 Science, Technology, & Human Values 47(1)

ORCID iD
Brian Salter https://orcid.org/0000-0002-0779-2712

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Author Biography
Brian Salter is a professor of Politics at King’s College London. His research deals
with the political sociology of power in the domains of science, health, and educa-
tion focusing in particular on the role of ideology, culture, and markets in the control
of knowledge. In biomedicine, he explores the global politics driving the govern-
ance response to new health technologies, the impact of the emerging economies of
the Global South, and the role of religion and bioethics in that process.