Banking On The Body With Kara Swanson

In this episode, UVA Law students Mary Beth Bloomer and Anu Goel join me to talk to Kara W. Swanson, a Professor of Law and Affiliate Professor of History at Northeastern University and a visiting scholar at Princeton University’s Institute For Advanced Studies. Professor Swanson is an accomplished scholar, legal practitioner and scientist whose chief interests are in intellectual property law, gender and sexuality, the history of science, medicine, and technology and legal history. In 2021, she was selected for the Law & Society Association’s John Hope Franklin Prize, which recognizes exceptional scholarship in the field of race, racism and the law. 

Professor Swanson's research has been supported by the Mellon Foundation, the National Science Foundation, the National Endowment for the Humanities and the Lemelson Center for the Study of Invention and Innovation, among other funding organizations. We’re discussing her 2014 book, Banking on the Body: The Market in Blood, Milk and Sperm in Modern America, published by Harvard University Press.

Further Reading

Kara Swanson, Banking on the Body: The Market in Blood, Milk and Sperm in Modern America (Harvard University Press, 2014).

Kara Swanson, “Rethinking Body Property,” 44 Florida State University Law Review 193 (2016).

Almeling, Rene. Sex cells: The medical market for eggs and sperm. Univ of California Press, 2011.

Krawiec, Kimberly D. "Sunny samaritans and egomaniacs: price-fixing in the gamete market." Law & Contemp. Probs. 72 (2009): 59.

Krawiec, Kimberly D. "Egg-donor price fixing and Kamakahi v. American society for reproductive medicine." AMA Journal of Ethics 16.1 (2014): 57-62.

Krawiec, Kimberly D. “Gametes: Commodification and The Fertility Industry” forthcoming in The Routledge Handbook of Commodification, Vida Panitch and Elodie Bertrand eds.

Transcript

[00:01] Kara Swanson: Yeah. I've often characterized this anxiety around body products as people don't want a body product from a person that they don't want to sit next to on a bus. 

[00:21] Kim Krawiec: Hey Hey, everybody. Welcome to the Taboo Trades podcast, a show about stuff we aren't supposed to sell, but do anyway. I'm your host, Kim Krawiec.

[00:36] Kim Krawiec: My guest today is Kara Swanson, a professor of law and affiliate professor of History at Northeastern University and a visiting scholar at Princeton University's Institute for Advanced Studies. Professor Swanson is an accomplished scholar, legal practitioner, and scientist whose chief interests are in intellectual property law, gender and sexuality, the history of science, medicine and technology, and legal history. In 2021, she was selected for the Law and Society Association's John Hope Franklin Prize, which recognizes exceptional scholarship in the field of race, racism, and the law. Professor Swanson's research has been supported by the Mellon Foundation, the National Science Foundation, the National Endowment for the Humanities, and the Lemelson Center for the Study of Invention and Innovation, among other funding organizations. Today we're discussing her 2014 book, Banking on the Body: the Market in Blood, Milk and Sperm in Modern America, published by Harvard University Press.

[01:45] Kim Krawiec: Thanks, guys, for joining me today to talk to Kara Swanson about her book Banking on the Body. Why don't we first have you both introduce yourselves to listeners?

[01:58] Anu Goel: Hi. My name is Anu Goel. I'm a 3L at UVA law. I'm from Richmond, Virginia, and I'm really excited to be here to talk to Kara today.

[02:07] Mary Beth Bloomer: Hi. My name is Mary Beth Bloomer. I'm a 2L. I'm originally from the Philadelphia area, and I'm also super excited to be here and to talk to Kara about this.

[02:16] Kim Krawiec: Great. Yeah. I'm looking forward to you guys meeting her. I think you'll both like her. So, you both volunteered to be hosts of this particular episode. So, I first wanted to just ask you what made you want to do that? What drew you to either the topic or the author or the book that caused you to choose this episode?

[02:38] Mary Beth Bloomer: Yeah. So, I found the juxtaposition of blood and breast milk really interesting. I think blood donation is super ubiquitous in the United States, especially on college campuses. I think it's just like, everywhere, most people are familiar with it. And I found that contrasted with breast milk super interesting, especially because breast milk, I think, is a little less taboo than it has been in American society. But it's still something that I definitely don't know a lot about, and I think is something that's still definitely less normalized than blood donation and all of that. So that really stuck out to me. And I love history, so it seemed just like a good fit, and it seemed just really interesting overall.

[03:21] Kim Krawiec: Yeah. And what about you, Anu?

[03:24] Anu Goel: To be honest, the first thing that drew me to it was the title of the work, because I think these are, like, Mary Beth said things we think about, especially, like, blood banking, but just kind of seeing it written out like that. In my mind, I'm like, okay, I know what a blood bank is. But then seeing breast milk banking and blood banking and kind of adding a more human narrative to it was really compelling to me, and I just had a feeling I was really going to enjoy the work, and I did. And like Mary Beth said, I also really enjoy history. So, the Anecdotal introductions as well were really captivating for me when I was just skimming over it. So that's kind of where I was coming from, just getting this new kind of perspective on something that I'm at least somewhat familiar with and just really wanting to learn more.

[04:20] Kim Krawiec: Yeah, I totally agree with both of you. I read the book several times, actually, and I feel like every time I read it, I learn something new that I either forgot about or that I didn't focus enough on the prior time that I read it. It really is such an incredibly rich historical treatment that also has so many implications for modern debates. It's really an amazing piece of work, and I think we're really lucky to get to talk to her about it today. Anu, what else are you interested in talking to her about? What do you want to ask her? What do you want to hear from?

[05:00] Anu Goel: So I am at least somewhat familiar with blood banks, but I don’t have as much background on modern breast milk distribution, so I am very interested in getting to hear more about that. Because when I think about it, like Mary Beth said, it’s almost like everyone’s familiar with blood banks, especially if you’ve had the opportunity to attend college, you kind of see blood drives and stuff like that pretty regularly. But in my 25 years of age, I don’t think I’ve ever come across any information or advertising for breast milk and stuff like that. So, I’m very interested in learning more about kind of breast milk stations, and I'm also really interested in the kinds of things that compel people to go out and donate, whether it be breast milk or blood, especially in the context of blood. Like she mentioned, there was a big rise after certain historical events, like World War II, but I talked about this a little bit earlier where we didn't really see that with COVID, and we actually saw a drop. So, I'd really love to understand what kinds of big historical events compel people to kind of do these things for just altruistic purposes.

[06:26] Kim Krawiec: And Mary Beth, what about you?

[06:27] Mary Beth Bloomer: Yeah, so I'm interested in just kind of, like, the history of discrimination and prejudice, both in blood banking and breast milk banking systems. I think it's really interesting how it seemed like in the excerpt we read that a lot of America's history with discrimination and prejudice was kind of running alongside how breast milk banking was developed and also blood banking. So, I'd love to hear the author talk more about that. Also, there was like a really big push just in what we read about having this kind of moral donor and having this kind of idea of an ideal donor for both breast milk and blood. And I just find that whole concept really interesting, especially when today we don't know if you get blood at the hospital, you don't know the exact person that you're getting blood from or anything, and you just assume, oh, it's fine, it's blood. Or at least I would. I don’t know. So, I find a lot of the moral underpinnings really interesting with this discussion.

[07:30] Kim Krawiec: Yeah, as I expected, there was lots of discussion in the class about a variety of aspects, but especially the racial aspects of what she wrote about. In particular the segregation of blood, as well as the sort of search for donors with particular moral properties that in some cases arguably had some relation to safety and in other cases just clearly didn't really, right? And so, I think that's going to be an interesting discussion to have. Anything else?

[08:00] Anu Goel: No, I don't think so. Just excited to get to meet Kara and get the discussion rolling. I think everybody had really interesting questions.

[08:08] Kim Krawiec: I am too. All right, so let's join the group. Hey, Kara, I'm glad that you could join us.

[08:14] Kara Swanson: Thank you all for reading the book, and it's just great to see you all.

[08:18] Kim Krawiec: Mary Beth, why don't you start us off?

[08:20] Mary Beth Bloomer: Yeah. Hi, Kara. Thank you so much for joining us today. Like Kim said, we all loved reading and discussing your book. So, we're all super excited to be here. So, we have a couple questions for myself and some of my classmates, just kind of about this idea of the ideal donor. Specifically, I found it really interesting that in blood selling industry, it was very male dominated, and there was kind of this idea of the professional male blood seller, whereas in the breast milk industry, it was still seen as something altruistic, which, of course, was women donating breast milk, and charitable. It was seen more as like a charitable service, while men it was seen more as a career. So, I'm curious if you see these gender norms at play in how modern body banking systems are run and advertised, like in sperm banks, or, for example, in donated egg or embryo banks.

[09:21] Kara Swanson: That is a really terrific question, because gender norms are really deeply ingrained in gamete markets. For example, in 2011, a group of egg providers actually sued the American Society for Reproductive Medicine about the voluntary cap that they had on compensation to providers. And that cap, a ceiling on compensation, was never even considered for sperm providers. And the women who brought that lawsuit and their lawyers pointed out the very gendered nature of this idea that women needed to be protected from being offered too much.

[10:05] Kim Krawiec: Just a note to listeners: That lawsuit that Kara is referring to was generated by a 2009 paper that I wrote, Sunny Samaritans and Egomaniacs Price Fixing in the Gamete Market. I'll put a link to it in the show notes as well as a variety of other papers that I wrote about that litigation, both before the case was filed while the litigation was ongoing, and then more recent papers that I have written discussing the aftermath of the case.

[10:36] Kara Swanson: and when I was writing this book in the 2010s. So it was the looked on websites and if you looked on an online sperm bank website, it's front and center: If you donate to us, this is how much money you’re going to make, right? And if you look at egg brokers, who were generally what was being used at the time because at that time egg freezing was not yet a thing, you had to page down quite a ways before money was mentioned. It was all talking about what it would be like to be an egg donor and how you could do this great thing for families, which is all true, but it was very much the money was supposed to be much less important. And as you point out in when you were thinking about this question to begin with, we have always had a sex segregated employment sectors in this country, right. That there are jobs that are pink collar and blue collar and historically pink collar jobs are paid less. And that has to do with questions of things like the idea of a family wage, that a man has to be paid enough to support a family and a woman's only earning for pin money, right? That stereotypical idea. I think when we're looking at gamete markets, we're looking at women's reproductive function, right? We're talking about eggs and we're talking about breast milk. And so, we're talking about women as mothers. And as mothers, you are supposed to be nurturing and maternal and life giving, right? And so, it's much more taboo in Kim's favorite word, to be transactional about those sorts of reproductive capacities. And in other chapters in the book, I talk about how mid-century milk sellers are often talked about as mothers, like the early ones, even when they're earning money, right. That we're going to put them in a separate category. They're not sellers. And that, as you say, just continues up to the present and is very dominant in the gamete industry and the big difference between how egg providers and sperm providers are treated.

[12:52] Kim Krawiec: You know, Kara, one of the things that I find so fascinating about the work that you've done on blood donation is that in some ways the gendered notions in gamete markets or in surrogacy or breast milk aren't as surprising to me given that they are in some ways inherently gendered or inherently about motherhood or fatherhood. And yet there's nothing inherently gendered about blood. And you document a very similar distinction there, right. And as you note, it makes sense given the sort of pink labor and the way in which we have sort of always gender coded, I guess, different jobs. But it's not something I expected until I read your book, and it surprised me.

[13:42] Kara Swanson: It surprised me too.

[13:43] Kim Krawiec: Oh, interesting. Okay.

[13:44] Kara Swanson: And when I found this sort of this mid-century description of the lady Dracula's at the blood bank who were going to take your blood, I realized that it was not just a gendering of the providers, but it was also gendering of the space and the workforce. Right? That blood banking became a situation in which men were giving and women were doing the taking. They were arranging the facilities in which this happened. And as you say, it's easier to realize how gametes are. Well, of course they're going to be gendered. Well, part of what I think we learn when we look at how blood banking has been gendered is that it helps us see the ways that gamete donation doesn't have to be gendered. Right? That we realize that it's constructed there just as it's constructed in blood, even though it's maybe a little harder to see. 

[14:37] Kim Krawiec:  Great. Thank you.

[14:38] Mary Beth Bloomer: We're going to go to my classmate Julia, who also has a question about kind of the ideals behind people who are donating blood.

[14:48] Julia D'Rozario: Thank you, Mary Beth. And thank you so much, Kara, for being here. So, on the topic of the ideal donor, it seems to me that the ideal donor in the current blood supply system is very at odds with the ideal donor A century ago. You mentioned in your book that doctors in the 1920s wanted businesslike donors as opposed to starry eyed, romantics, and intentionally downplayed the lifesaving aspect of the act of giving blood. And by contrast, in the current blood supply system, we seek altruistic donors, and we appeal to “love thy neighbor” communitarian ideals. Was this dramatic switch solely a result of the financial pressures of the great depression? And if so, is there a reason that the US hasn't ever returned to paid donation for blood?

[15:39] Kara Swanson: When you ask that question, it makes me think of the last time that I gave blood, and the med tech said to me, you've saved three lives today. She was telling me that that one pint was going to go to three different people. Yes, that's what we're told. And you're right that it's really dramatic difference, right, to think about blood sellers and sort of lifting up professional sellers as opposed to giving for the sake of the community. But actually that switch, and it is a dramatic switch, didn't happen in the 1920s and 1930s. Blood selling was a significant part of the US blood supply system until the mid 1970s, which is when the American Association of Blood Banks set a target for voluntarily getting rid of paid blood suppliers. And as you probably know, is still the dominant means that we use to get plasma, right, as opposed to whole blood. So, the factors in that switch are various, and they're not exactly what sort of I had believed before I started doing this research. I believed that the factors were that we were trying to clean up the blood supply, right? We had to get rid of the paid donor in order to have a safe blood supply. But what I learned when I did this historical research was that, first of all, one of the big factors in this was World War II. That that was the moment in which we were taught that giving blood is a community oriented activity. And we were taught that because the US Military was being very instrumental about its wartime planning, that blood transfusion, having become a successful medical treatment, now made blood an important resource for war. In fact, one of my favorite stories about World War II is when they're planning the D Day invasion of Europe, right? And it's a really big secret when they're going to invade, right? And Eisenhower's over there, and they've got all the troops are building up in England, and they were doing various things to try and throw the Germans off and tell the Germans they were going someplace else. And they had fake people running around in England, like, driving trucks, trying to convince the Germans they were about to land when they weren't. One of the few people that knew the secret was the person in charge of blood banking. And he knew the secret, and he also had to do fake things. So, he kept actually drawing a bunch of blood and then throwing it out because it aged out, because he knew that actually the D Day invasion was going to happen, and then he'd do it again. So, blood was part of this whole D Day planning. So, it was the military that was telling us that we needed to do this through the Red Cross that we're used to today. But at the same time that we're being told, give blood to the troops, hospitals are still paying people. That's how they're getting blood. And it was actually a big fight after the war. The Red Cross wanted to continue get blood without paying people, give it to whoever needs it. And it was the medical profession that fought them tooth and nail on that because they thought that free blood was the first step on a path to free medicine, free health care, and in fact, what they called socialized medicine. And that was an assault on both prestige and profit. So, they fought against this idea of the altruistic blood donor. And it was actually lawyers that helped make the switch, right? Because lawyers started developing product liability law, which you talked about in tort class, that new idea that you might be strictly liable if you made a dangerous product, that it's more important that the producer bear that cost than the recipient. And lawyers are like hey, if you get a pint of blood, that ends up causing you a lot of trouble, that seems like a great thing for product liability law. The supplier who had all the control, they should be liable, not the individual patient. So, they went into courts and said, Blood's a product. And that really freaked out the blood bankers. And they, actually, one of the reasons they backed off between from paying for blood and for how they billed you on the blood is that they wanted to say, no, it's not a product that we're buying and selling. It's a service, part of the medical service of caring for you and blood is just sort of slipped in there as part of the service. It's not a good, so you shouldn't hold us strictly liable under product liability. And then the third thing that happened that made that dramatic switch that you pointed out from paid blood sellers to unpaid is racism, pure and simple racism. At the same time that the civil rights movement, the mid 20th century civil rights movement, brings an end to dejure segregation in the United States, right.? Dejure Jim Crow. That is the moment in which blood banks say, all right, well, we're not going to be labeling blood with the perceived racial identity of the donor. We're not going to be segregating, but we can move from paid to unpaid providers. And that is a proxy for eliminating these desperate, poor people who might be dark skinned as providers in favor of these well to do, civic minded people who are giving not out of financial need, but out of the goodness of their heart and just so happen to be more likely to be white, right? I think there's no question that the coincidence of those events is motivated by American racism, which, as we know, certainly was not being eliminated by the new laws that were being passed.

[21:40] Kim Krawiec: Kara, I wondered if you could just discuss your view as a historian about the role that Richard Titmuss’ work played in this progression. Has it been overblown in some accounts of his influence in sort of moving us away from a commercial system?

[21:59] Kara Swanson: Right. Well, I focused on Titmuss’ reception in the United States. So, we have to always keep in mind, right, that he's writing from his position as a left wing academic in post war Britain with his particular agenda, and then his book is brought over to the United States and becomes extremely influential and causes a lot of angst in the United States. That what he's telling the difference between gifts and commodities is really important. And I think that in the US context, that the anxiety that he caused and the great strength of the adoption of yes, gift versus commodity is the key issue and we need to be on the gift side of this equation here is related, as I said, to American racism and the changes that had just been happening in the last few years where hospitals are told you have to stop segregating. During the civil rights movement of the 1960s, what had been informal racial segregation of blood banks, some southern states actually passed laws requiring racial segregation of blood as part of their resistance to the civil rights movement. So, they were actually hardening their practices in the same way that they did things like shut down the public school system rather than desegregate. So, blood comes in the middle of that fight. And as I said, how Titmuss is read in the United States I don't think can be separated from that. Empirically, and I don't know if you've discussed this, it’s not clear that Titmuss is right in his approach.

[23:46] Kim Krawiec: We discuss it all the time. It wouldn't even qualify as empirics today, quite frankly, his analysis.

[23:54] Kara Swanson: Right, but it was incredibly sticky in its analysis. And that line drawing where we're going to focus on payment to the provider, whereas in previous decades, it's been all about actually whether the recipient is going to pay or get it for free. Right? How can we get breast milk to the babies that need it? Can we charge more to wealthy families and less to poor families? That's where the doctors are thinking about the money side of the equation, and Titmuss moves it over to the provider side of the equation.

[24:30] Anu Goel: Keeping with our theme of the ideal donor, we're moving over to our next student, Dennis.

[24:36] Dennis Ting: Yeah. You know, I found it interesting when I was reading your piece about how regulating certain types of taboo trades can create more problems for those interested in being a part of the market. So, for example, it was really interesting, you know, seeing how the introduction of regulations in the blood market in the early 1900s was met with some resistance from those professional donors who some argued made the process a lot more cumbersome. Do you think there's kind of the similar worry that legalizing and regulating these other markets, something that comes to mind is like prostitution, may cause there to be a drop in participants? And how do you address those concerns to ensure the benefit of having those markets is maximized while still ensuring the safety of those who participate?

[25:24] Kara Swanson: Yeah, I mean, that's a really deep question, and prostitution is one example. But we can look to the gamete market that I was discussing with Mary Beth. Several countries have put in laws requiring that children born from donor gametes must have the right to know the identity of the gamete providers. And in those countries, the number of people willing to provide gametes has dropped such that, in fact, some countries can't meet their own needs, and they're going to places like the US where that law is not enforced and buying sperm, particularly from the United States. So, your question is pertinent and is, of course, a reminder that all markets have constraints, and those constraints have consequences. And the question that I want to ask is, should you say, well, how are you going to maximize the benefit? And the first thing, of course, is, what is the benefit you're trying to do, right? Keeping a supply of the body product and keeping providers and recipients safe and maybe and I think should be part of it, getting it to those who need it without ability to pay. Because we're talking about health care here, right? We're not talking about widgets. And what I take away from this history with respect to that question, which is a question, of course, involving regulation in all sectors of our lives, not just body product markets, is that this history tells me there's a lot of variations that have been tried. And if there's one takeaway that I hope people have from the book, it's that you can go beyond the pay providers, don't pay providers as your two levers to push, right. As you try and do what Dennis is saying, how can you do this? Oh, unintended consequence. What can we adjust? And that's not the only place that we can adjust. And I think we were at a point maybe 10-20 years ago where that really was the only question being asked. 

[27:40] Mary Beth Bloomer: In that vein, Kate, my classmate, has a question also about markets, professionalism, and everything that kind of goes along with that.

[27:50] Kate Granruth: Hi. Thank you so much for being with us today. So, kind of going off of what Dennis was saying. I'm curious what your thoughts on to what extent the process of body banking necessarily dehumanizes its participants? Obviously, there's some like, taking the personhood out of people when you're trying literally, when you're trying to you sort of donate blood and you don't really wonder, like Mary Beth said earlier, where that blood came from, for example. But at the same time, then we lead into things like in the book, the wet nurse has been referred to as like a dairy cow. And in Talbot's Labs, it was sort of like monitoring laboratory subjects the way that a lab rat might be. And so, I'm curious your thoughts as to if you feel like individuals consent to these processes actually mitigate dehumanizing consequences or if professionalizing the service mitigates that dehumanizing process.

[28:42] Kara Swanson: Well, we could spend a lot of time talking about consent and what it does and does not do in the medical context. I was actually on the American Society for Reproductive Medicine website earlier this week and noticing that they are reminding their members that what constitutes informed consent for legal reasons is not the same as what might constitute informed consent. For ethical purposes and that they should consider consent as an ongoing process, not a one and done sign the form, which I thought was a great leap forward for professional side to be thinking about that. So, putting consent aside, whether that can solve anything or not, I think what’s really interesting about your question is how you’re noticing that body banks, institutions that manage this transfer of body products from provider to recipient, dehumanize, and do they necessarily dehumanize? And I think history teaches us that the way that these banks operate, the words that they use, Kate was pointing out some words, the people they have as employees, right, we were talking about using women predominantly in blood drawing spaces. They all help shape the experiences of providers and recipients and how they feel about it and whether they feel dehumanized or not. And again, it's not dependent on whether they are paid or are volunteer. So, I have two examples in later chapters that talk about this a little bit. One is a post World War II blood bank that was established in Evanston, Illinois in 1955. And for those of you who aren't familiar, it's a well to do suburb of Chicago on the North Shore. And this bank was founded by lay women, young, white, stay at home moms who became convinced that if you had a premature child that donor breast milk was the child's best chance of a good start in life. And they set up a bank in which they were collecting. They had a milk run. They would go out from house to house and collect, basically from their neighbors, from their peers, collect the milk that was taken to a hospital and processed and then given out to other women. So, this was peer to peer, no money changing hands. And that surveillance that happened in the 20s and 30s is gone or is moderated. It's more like the watchful eye of a neighbor. Yes, the person who's come into your house to collect the milk can see if you're a sloppy housekeeper or a neat housekeeper and how well you're packaging the milk that she's picking up, but then nobody's watching you express the milk or wash yourself. You've got directions, but you're trusted to do that. And because we're all sort of at the same level, it's not somebody in charge and somebody underneath. And I was thinking also about the World War II Red Cross blood collection system. The Red Cross had it down to a science. It was an assembly line, how many donors they were going to bring in each day, to which center. They had regional centers throughout the country. They had a goal of how many pints they were going to collect. Where they were going to go. It was, they were very explicit about talking about it as an assembly line. So that's dehumanizing. Right? You're just a part in a moving machine. At the same time, they developed this idea of having these volunteers, they called them gray ladies. I don't know why it sounds a little spooky, but whose job it was to treat the people going through this assembly line as individuals and make everybody feel happy and appreciated. And then they also, at the end, near the end of the war, they came up with this very clever plan. So, the blood that they were collecting during the war was mostly made into plasma. At the time, that was thought to be the best way to use it. And plasma does not have to be divided by blood type. So, they would pool everybody's blood together and make the plasma, and then they would actually dehydrate it and make it into a powder. So, what was going overseas was these little boxes in each had a bottle of dehydrated plasma powder that the medic in the field would add water to shake and infuse. So, in that each little box was blood from many people. You don't have individual thing, but the Red Cross came up with this great idea. At the end of your donation time, while you're in the waiting area drinking your orange juice and having your donut and chatting with the gray ladies, you can write your name on a box and say, this blood symbolizes this plasma in this box symbolizes the donation given by so and so, and I'm doing it in honor of. And you could name a soldier or sailor from your family. And then when the box went to the field, the recipient could see that box. So suddenly we're rehumanizing this assembly line product that's not even a one to one person gift anymore, but through that writing on the box, they were inserting that back in. And this is, again, just one of the chief themes of the book, right? It's not that body banks are humanizing or dehumanizing, it's how they are run.

[33:55] Anu Goel: Kind of keeping in that theme of the pursuit of humanizing blood banking processes and body banking processes in general, we have one more question from one of my classmates, Aamina.

[34:10] Aamina Mariam: Yeah, hi. So, you kind of touched on it at the end of your answer there. I was really surprised that the efforts to humanize the blood banking process was successful because the process itself still seemed very mechanical. And so just changing that minor part of having all the donors sit together or being able to write a dedication on the box, those seemed like very minor changes that only affected the donors. It didn't change the process of collecting and sending the blood or plasma. It didn't change the process as a whole. So, I was wondering if you thought that it really did transform the whole process into a personal one, or if it's just the illusion of intimacy and that's what was more important for us as a society, 

[35:01] Kara Swanson: Right. I mean, I don't know if illusion is the appropriate word, but we all have feelings going in and coming out. And the Red Cross worked deliberately to set up a set of feelings. Their goal, of course, was a set of feelings that would make you want to come back in two months and give again and to tell your next-door neighbor to give, or the person down the street who always says that they're afraid of needles, right? Oh, come on. Actually, they're really nice. It hardly hurts at all. Right. That was their goal, right? Their goal was completely instrumental, but the feelings were real. And the feelings of the soldiers in the field when they can see those boxes were also real, that there's a person out there that cared enough to take their time to do this, and they don't know me, but they know this other person who's serving in the armed services, and somebody there is thinking about you. So again, it goes back to this question we keep having. Does it necessarily have to be this way or that way? And sociologists have told us with money, and it's the same thing with body products. We constitute the meaning collectively, and we can be strategic about how we do that.

[36:24] Kim Krawiec: Kara, I wondered if you could speak a little bit about medicalization and its impact on sort of the intimacy versus, I don't know, distance that is in some of these transactions. As I was reading, really, both of the first two chapters, both wet nursing and blood donation begin as what I would at least characterize as very intimate procedures, because they're direct you know, you have the baby at your nipple or you have your vein directly connected to somebody else's. And then as they became more medicalized and standardized, some of the things that I think that Kate and other students thought of as being dehumanizing began to be introduced. Things such as I remembered, especially with the wet nurses, how they would begin disinfecting them and then they would cover them from head to toe and leaving only the nipples exposed. And then the blood becomes more distant from the person, of course. And some of this related to safety, but I didn't know if all of it did, based on your description, and whether some of it was a desire for control, just for control's sake, because it's easier. I don't know. I just wanted to get your thoughts on the role of medical professionals, or maybe just professionals more generally in contributing to an environment that seems less personal, so that then they almost had to backtrack and introduce methods to make it personal again.

[37:52] Kara Swanson: Yes. Those early doctors that were setting up mother's milk stations were very interested in control. And there was gender imbalance and class imbalance with the women that they were dealing with. And the doctors felt, the male white elite doctors, felt completely justified in treating these women as inferior, as servants, based on a tradition that wet nurses had been inferior servants, and they were going to be scientific about it by controlling those bodies as much as possible. But you know, that’s for them, that was the great moment when they could stop having to try and control the wet nurse's body because, gosh darn it, those women just always kept doing what they wanted to do and nursing the baby how they wanted to nurse the baby and eating what they wanted to eat and drinking what they wanted to drink. So, if they could move to the milk in the bottle and then the doctor could see it and see how much was there and you could take it to the lab and you could measure it, that was a great step forward to them. But again, this is not a one-way ratchet. Right? Milk banks in the mid 20th century, like the one I discussed in Evanston, those were lay women that were in control, and they were not interested in control of the bank and they were not interested in controlling each other in the same way. I described the Evanston Bank, which was a relatively formal bank. It had a medical director, it had hospital affiliation, the hospital was processing the nurse. But still later on there were what was called kitchen milk banks, where one woman just decided to collect breast milk in her home and keep it in her freezer. And by word of mouth, you would know if you needed milk for your baby, she was somebody to contact. And I thought about what those women were doing the same way that I thought about how mothers at that time and today are constantly passing around things like outgrown baby clothes and toys and cribs. Right? Women do that to help each other out. And that's a very different model than the medical control model. So again, we see a back and forth, a pushing back and forth and a change over time. And I think that, you know, due to the women's health movement and changes in the second half of the 20th century, the medical profession is not quite so paternalistic, deliberately using that gendered term in the ways that it was in the 1920s. But, yes, it still considers itself a hierarchy. And of course, yes, we still go to a doctor because we think they have expertise that we don't. Right? I mean, there's always going to be that imbalance. 

[40:42] Kim Krawiec: Great, thank you.

[40:44] Anu Goel: So, shifting gears here a little bit, I wanted to cover something that came up quite a bit during our discussion, which was kind of about the motivation to donate, especially in the context of crises and disasters. So, I know that in your work you had discussed some historical examples that promoted blood donations, like after World War II. And we kind of understand that as patriotism as being the primary motivator there. But then, just to put it in context for something for us and our listeners, data kind of has shown during and after the COVID pandemic, we actually saw the frequency of blood donations go down, even though we had a greater need at the time. And then conversely, even though there was no shortage of blood following 9/11 and blood banks had actually gone out and let individuals know that as well, thousands of citizens and other individuals were going to blood banks to donate. So, I was kind of just interested more in your perspective on if there are certain types of crises and world events and disasters that might encourage more altruism or maybe if, over time, the attitude of personal responsibility for the public good and health have changed? So, I just wanted to hear more about that.

[42:22] Kara Swanson: Yeah, that's a really interesting set of questions. And I was thinking about COVID I mean, historically, particularly since World War I, in which we were taught as a nation that our blood could be of use to the community as a whole. And we were rewarded for that. Right. That people in the United States are quick to rush to the blood bank when there's a disaster. And it could be a big time disaster like 9-11, or it could be a smaller disaster, like a local news where there's a really bad crash or something, that people will actually call up the blood bank and see if they need blood. The statement of those doctors in the 1920s that we don't need the romantic stereo donors. I mean, that's what the blood bankers were thinking during 911 too. Like, thank you very much, we actually don't need the blood. And if you all give it now, it's going to age out before it can be used. The blood banks were actually frantically trying to schedule people to come in in like a month, right. The people that were lining up on September twelfth, that's that constant problem there. And is COVID an example that that's changing? And COVID is hard to tell. Right. Because COVID was not a blood shedding emergency. Right. The problem with COVID and the blood supply was that we were all told to stay home. We did. And then the blood supplies just Dwindled and Dwindled and Dwindled. Right. And the people that had been in the habit of giving stopped giving perhaps because they were in classes that were really worried about going out in the public and going out to hospitals and that there was just sort of a really bad negative feedback loop. I will say that since we've had COVID, people are still responding to disasters, which we've had plenty of, right? Hurricanes, fires with that. So I don't think we've lost that. The other thing I was thinking about with response to your question is sociologists have told us that multiple ways in which our sense of national community is being frayed and has been frayed over the last 10, 20, 30 years, right? From the bowling alone, which I think was the turn of the 20th century, to the fractionalization through social media. So can blood giving both be encouraged and maybe, as Titmuss said, be a glue? And as a historian, I think about this in terms of historical context. I don't see it as like we had a high in terms of our altruism and thinking about blood donation in 1942 and it's just been downhill ever since. First of all, the Red Cross had a heck of a time getting us to the blood donation centers during the war. They worked really hard, and part of what they learned to calculate was how many people would say they would show up and didn't show up. So they had to get almost twice as many people scheduled per day or 50% more scheduled a day than they wanted to take blood because so many people would not show up. Right. It's not that we are collectively so much worse than we were 60 years ago. At the same time, as we perhaps know, the Red Cross is also really good at getting us to show up these days, right. So they can do things like have sports teams, competitions, or give us balloons or have puppies to pet or offer a donation to our favorite charity. There's all kinds of things that will get us to show up again. It's not the nature of the disaster. It's not a one way trip in one direction or another. It's how intentional we want to be about this. But I think your question really raises an interesting point, which is that maybe it's a useful thing that we have that impulse, and it's worth trying to keep that because it is one place in which we meet our neighbors that we wouldn't otherwise meet. By the place, I mean, in that room where you get your donuts and your really bad orange juice.

[46:22] Mary Beth Bloomer: I will say that the donuts and orange juice were always a big draw for me. Switching gears a little bit, a couple of my classmates had questions about how scientific innovation and social taboos relate to each other. So we're going to go to my classmate Darius to talk about that.

[46:40] Darius Adel: Hi, Kara. Very nice to meet you. To me, the most interesting part of your work was reading about how blood donation technology evolved over time. I'd like to know your thoughts about what methodologies or technologies you think may become integral to blood donation and transfusion in the future. For example, I can see how lab grown blood could upend the whole system in a similar way to how advances in formula kind of change the breast milk landscape.

[47:13] Kara Swanson: Right. And I was thinking about that question with an example from the history of medicine in insulin, right? Insulin was one of the first medical therapeutics to be created by recombinant DNA and grown in bats, and that replaced the previous way of getting insulin, which was to extract it from animals. I think pigs right. Became much more available, much less expensive, and stopped being a body product, albeit from animals, and became a lab product. While my historical knowledge really does not allow me to predict the future of biomedicine, I think the question that you're asking is, well, what happens when something that I've defined as a body product can be obtained in a way that's not a body product? It comes from the lab rather than a body. And we might think collectively, we might hypothesize that that would reduce the taboo, right. That all of a sudden, all these issues that we've been talking about are going to vanish. And I want to say two things about that, right? Which is that science and technology definitely play a role and can help dehumanize or use that word can help de individualize something, and that might reduce anxieties and taboos. But again, it comes more out of sociology than the technology. It's all about how the interaction is shaped, even if it's coming out of a lab. And I think about that with respect to the HeLa cells. So those are from everybody's familiar with the HeLa cells. That originally was a cell culture from the body of a woman named Ken Mano Lax, right. And HeLa cells that you call up an organ supply company today are a product of a lab. No question about that. Right. But in the past ten years or so, we have been rethinking the context of HeLa cells and suddenly thinking about them as a body product. They originated from Henrietta lapse's body. So we could think about lab made blood or 3D printed organs, but where is the substrate coming from? Where is the original genetic data coming from? We could think about it as a body product. And whether or not the taboo nature, the anxiety, the dehumanization goes along with those new technologies is in some sense up to us. And maybe we want to stop and think, do we want to say, yes, this is great, this is like insulin from the lab rather than from a pig, we should just go with it? Or does the HeLa case make us think if we dehumanize too far, we've lost sight of something important? We have mistreated the originating body in ways that we are not interested in replicating.

[50:13] Anu Goel: We have a question from one of our classmates, Kate.

[50:16] Kate Granruth: Yeah, so I was really interested in the reading this term scientific motherhood came up, right? And at first, that sort of concept and the idea that and I put the quote here, that quote, “infant feeding choices should not be left to mothers.” At first, that kind of struck me as like, offensive, given women's various motivations for not wanting to breastfeed. Maybe that's just because I'm a formula baby myself. But at the same time, clearly the early days of supplementing with milk caused a lot of health problems in babies, like when it was just pure dairy milk ,and upped that mortality rate. And I was sort of thinking about the modern-day analogs for me here, outside of the body banking context. Like, parents who do not have their children vaccinated or don't let their children eat red food die thinking it causes behavioral conditions. And so it made me wonder, sort of going back to that question of how do we balance scientific innovation with a respect for personal autonomy? To what extent is innovation all like, paternalistic innovation? And when are we sort of okay with that when it results in fewer dead babies?

[51:26] Kara Swanson: Yeah. The paternalism question is definitely a really interesting question, although I wouldn't call innovations themselves paternalistic or non-paternalistic. Right. Paternalism, I think, really comes from the people and who's making the choice for who, as you said, the question of personal autonomy. So I agree, scientific motherhood was insulting to women and insulting to mothers and was an attempt to assert power and control in the ways that we've already talked about. And yes, too, it also know in some ways more babies did live and that led more parents to trust pediatricians, which led more people to look to the. This is we were reading about those early blood banks are before Dr. Slock, who was the first celebrity pediatrician that mothers would follow religiously. And there's been, of course, a series of them since then. And I've already mentioned that the women's health movement from the was a real chance to try and overturn that hierarchy and have a more partnership model, particularly with respect to things like lactation and childbirth, that women should trust their bodies and trust each other. And the La Leche League, which promoted breastfeeding at mid century, was women talking to women about breastfeeding. And as lawyers, I think we can watch what happens with the medical profession, right, this push and pull between how paternalistic doctors are being. But I think it's our job to think about, well, what boundaries do we want to set about that? When should the law intervene on behalf of an individual? You should wear a seatbelt. You have to wear a seatbelt. Or in the interest of the public at large, you have to vaccinate your children. Right. That's not just for your own children's sake. That's for the sake of all the kids that they are in school with. And as we as lawyers, as we're watching the paternalism medicine, also want to think about things like whether the medical profession is treating people differently based on different identities, based on age, perceived ability, perceived race. Right. Those are ways that the law can step in. So I like to think of the law as sort of, as I said, setting this outer boundaries in which there's things happening in the medical profession that maybe we as individuals, not as lawyers, would push back against. Or I would choose to go to this provider rather than that provider because I like the way that they're going. But I'm not sure that we need to have the law intervene in other places where I do want the law to intervene. So that's a non answer to your question.

[54:10] Mary Beth Bloomer: Kara, keeping in line with kind of you mentioned a little bit about race and other forms of discrimination, something that really stuck out to myself as well as many of my classmates was just how big of a role discrimination and prejudice played, especially early on in blood banking and breast milk banking systems. So my classmate Julia is going to ask a question about that.

[54:36] Julia D'Rozario: Hi again, Kara. Something that really, really stood out to me in your book is the history of recipients of blood and breast milk placing moral value on life saving substances based on the identity of the supplier. For instance, there was a preference for healthy married mothers as milk donors and for men with personal initiative as blood donors. You mentioned in the book that even aside from fear of disease transmission, doctors were concerned about personality traits and perceived morality and that this is part of why doctors sought to upgrade their suppliers from the most desperate. I was wondering if you think that this desire for moral donors could be one of the underlying social pressures behind the shift from paid to unpaid or money seeking to altruistic donations.

[55:35] Kara Swanson: Yeah, that's a complicated one and we have to put this in the context of scientific and medical knowledge. Right. So a large part of what you were reading about was a time in which DNA has not been identified and the idea of modern genetics is not being worked out. So people for a long time felt that blood and milk were actually substances that transmitted the characteristics of one person to another in ways that today we might think about genetic determinism and genes transmitting sort of determining your fate, which may or may not be medically true, but it's how we think about it today. So you're correct in what you're identifying, but I want to just put that in the context that it wasn't purely just fear, it was actually based in an understanding of how our bodies worked. But yes, you're absolutely right that, well, how can we stay away? How can we get to the more moral bodies? And that's a push and pull, you see. So Talbot started out with looking for wet nurses amongst what he considered to be a poor, desperate population. And he, as a doctor, actually wanted to uplift that population by turning them into wet nurses, by moving them into his residence. Right. By teaching them about caring for their babies, that he wasn't willing to abandon them. He was going to reform them into the type of body that would be good for a wet nurse, for somebody else's baby, a richer person's baby, and also would be a better person for their baby and hopefully able to care for their baby after their time as a wet nurse ended. So we don't always see doctors trying to go to unpaid for that. But I think definitely, I mean, the women in Evanston who were wandering around their neighborhood looking for milk for their babies, they weren't going into the South Side of Chicago, right. They were staying in Evanston and creating their own circle of reciprocity. There's actually an example from the 1960s in which, again, North Side of Chicago suburbs, they create a blood co-op where people go in and give blood. And then if anybody in their family needs blood, they can get it from that co-op. And that was a means of staying out of the city of Chicago's blood supply, which was much more dependent on paid donors. And then I'm just going to say this again because I think you can't say it enough racism, right? And that racism is part of it's not just moral value, it is moral value correlated with perceived racial identity.

[58:25] Kim Krawiec: Just wondered whether we still see you think that there are still remnants of this today, although taking a different form, but two examples that I thought of as you were just talking and as I read these chapters, Renee Almaling's discussion of the focus on egg donors. And of course, some of those traits are ones that one might care about because they will be transmitted, but others, including the notion that there were appropriate reasons for wanting the money, right. Greed not being one of them. But she's a student, she needs the money for tuition or to buy books was okay, but those are socially acceptable reasons to need money. And then I also just thought about the distinction between plasma donors and blood donors. I'm going to use the phrase donor for both of them, despite the fact that we know that plasma donors are paid, but they're both doing a good thing. And it just seems to me that the moral story around the two is very different. I guess in part that's because one group is paid and one isn't. But I think we also know that the population is different as well. And so I didn't know, I don't know, I just wanted to get your thoughts on that.

[59:40] Kara Swanson: Yeah. I've often characterized this anxiety around body products as people don't want a body product from a person that they don't want to sit next to on a bus and who you don't.

[59:59] Kim Krawiec: That's a great analogy, by the way. That's awesome.

[01:00:02] Kara Swanson: Right? And who you don't want to sit next to on a bus varies with time and place and your own identity. But as somebody who's ridden a lot of public buses and a lot of subways, there are people that I don't want to sit next to on the bus or the subway. Part of that is based on my background, and part of it is based on my perception of smell and dirt. I was thinking about this also that we have a very strong belief ever since the germ theory of disease developed in the early 20th century, that dirt is correlated with disease. Right. Even though we all know that if you wash your hands before supper, right, you've scrubbed up the dirt from playing that you've cleaned yourself up. It's not like it's part of your body, but that's also a strong thing there. So, this is the question that Darius is asking. Blood banks, technology can help us forget that or can clean up whatever that body was that we didn't want to sit next to on the bus into this nice little vial of sperm or milk or blood that we're willing to accept. Right? And if I'm taken to the hospital and need a blood transfusion, I am not going to worry for one instant about where that blood came from. Right. Because I have trust in the system, and I have trust in scientific medicine that it's going to be safe for me. And I'm glad that I have that removed if somebody else has done that work for me, which I don't think really answers the question, but it's how I've been thinking about that question.

[01:01:48] Anu Goel: Actually, that was a really great analogy. And I think it ties in well with what you also said about how racism plays a role in these kinds of instances. Unfortunately, I do still think that we're in a place where people might have attitudes about who they're sitting next to based on issues like racism and discrimination, based on ethnicity and things like that. And in that vein, we have a question from one of our classmates, Gabriel.

[01:02:22] Gabriel Josephs: Hi, Kara. We started out with a commercial system and then we went to a donation system. And I think the individualizing of the blood supply returns us again, I think to I'm imagining like a 23 ANDME but for blood. Part of the initial blood donation problem was the segregation of the blood supply and the need to kind of clean out dirty blood and then the donation system that sort of made that less necessary. I wanted to know, as technology evolves, are we going to get to a place where the sort of increasing rapidity of technology in the blood donation space makes us more able to kind of resegregate the blood supply or clean out dirty blood? Do you think that increase in technology will make it more likely that we will end up in a kind of system where the blood donation supply ends up getting highly individualized, where you can kind of pick out what? The race of the donor or things like that. And that ends up leading to a kind of de facto segregation of the blood supply, or reintroduction of a segregated blood supply by virtue of the commercialization of it.

[01:03:43] Kara Swanson: Yes, I could see that as a possible future. And the possibilities that you're raising are both technical, but they're not really beyond the technology we have at the moment. But they're also very much questions about how we're going to pay for health care and where we're going to get health care. Right. Are we going to have a very market based system where if you have as much money as you want to spend, which is pretty much how our reproductive medicine market goes, right. People that have the most money can be as picky as they want about their gametes and their surrogates and how they go about various forms. Of reproduction. And we could imagine a world in which you could be as picky as you wanted if you had all the money in the world about where your blood was coming from. And we've dipped our toe in that water, particularly during the AIDS crisis, people were definitely encouraged to go to the hospital and donate beforehand for an elective surgery, right, so they could get their own blood back. And that was a sensible thing to do, right, when we didn't have a good test for HIV. So, yes, I can imagine that more dystopian future. But I also can just return to the message that we've been exploring here, which is that sociology teaches us that we don't have to go in that direction. And as I think it's both a question of sociology, how we message, how we think about that. And I can't remember whose question this was, but I was thinking about this and I decided I didn't emphasize in the book enough that I didn't explore as a historian enough the racism of individual doctors when the doctors kept saying, well, we have to segregate blood in New York Presbyterian Hospital because that's what people want. That I wish that I'd spent more time trying to see if I could drill down into the biography of those individual doctors and say they really didn't want blood from the other, is what they were really saying, right? That because if they, as the doctor, had created a different message what do you mean you wanted to erase this thing? It's blood. Is blood. Like, do you want to live or not? Here it is. Right. If they had messaged that, it would have been very different and they were willing to not message that. So we do have power and control. Although Gabriel's question also, as I said, raises the question of how we pay for medicine and whether we have a concierge separate medical system for some people than others, which is basically what we have right now and whether we keep tolerating that.

[01:06:25] Kim Krawiec: I'm glad you mentioned the probing, the racism of individual doctors, because I was going to ask you a clarification question. Whether I was reading those chapters right. It wasn't clear to me from your description that they had evidence of this backlash that might be forthcoming from people who thought that the blood wasn't being segregated or whether they were just surmising that. And now maybe it's a fair assumption to make, especially in southern states, but Columbia Presbyterian, for example, just didn't strike me as a place where it's obvious that people would refuse to get blood if they thought that it had not been segregated by race. So that was my question for you. It was just a clarification of whether I was reading that right or whether you thought that you thought, based on your historical research, that there would have been or was quite a bit of pushback from I'm going to call them customers.

[01:07:27] Kara Swanson: Yeah. I mean, as a northerner and as somebody educated in the United States, I constantly underestimate the racism of the northern tier of the United States. And that's something I have to fight to correct. But we're talking about a situation in which medical schools are segregated. Right. There's black medical schools and there's white medical schools. And the fact that Charles Drew was doing his postgrad training at Columbia Presbyterian, he stood out like a sore thumb. Right. He had come from the world of black medicine. Black doctors were not allowed into the AMA. They had their own medical society. Right. So these white male doctors who are having these conversations are coming from a world where, of course, everything's segregated. That's how we've always you know, it's just a weird thing that somebody like Drew is an exception and he just shows up really, you know, we just can ignore him. And of course, they ignored him in very offensive ways. And by putting him in charge of a program in which they were racially segregating the blood, and he left and went back to work in more black oriented facilities, he didn't stay through the whole length of the war.

[01:08:41] Kim Krawiec: Thank you for that. I was actually intrigued by him and his sort of role, especially at Columbia Presbyterian.

[01:08:49] Kara Swanson: Yeah, he had a very distinguished career as a surgeon until he was tragically killed in the auto crash.

[01:08:55] Mary Beth Bloomer: Kara, you touched on the HIV AIDS epidemic a little bit earlier, and I know Dennis has a really good question.

[01:09:04] Dennis Ting: Yeah, last week we discussed how the Red Cross only just last year, applied the FDA's final ruling allowing LGBTQ plus individuals to donate blood. Or I think the specific term they use is males who have sex with males or MSMs. I was looking at your writing, and I noticed some similarities between the controversy over the ban on MSMs and how other marginalized communities were often excluded or disfavored when it came to donations, whether it was milk or blood. Do you see any other prominent gaps in donation policies that have yet to be covered? Is there kind of the next issue to be tackled?

[01:09:50] Kara Swanson: The issue that you've talked about right. The prohibition that's been in place for decades against allowing men who have sex with men to donate blood, it was really the big one. But I think about it in the context of that was a restriction that had a basis in science. It came out of that moment in which we realized that there was HIV in the blood supply. We didn't have a test for it, and we were trying desperately to figure out what we could do to keep it out. And of course, there were bans on people from Haiti and intravenous drug users. Right. There were a series of bans. And lo and behold, the one ban that's sticky, that stays around forever after we have tests is the one that discriminates against a group that is discriminated against in general in the United States law and society. I think about this with respect to the segregation policies, which were not well, I mean, there wasn't an FDA policy at the time, but they were nationally approved, no scientific basis at any time whatsoever. Right? And it really wasn't until the civil rights law started being passed in the federal Medicaid program in which the federal government could go to southern hospitals and say, you have to stop segregating or you're going to lose your federal money. Right. That that's where that changed. So the lesson for me from that recent switch and the embarrassingly long time that it took to switch is that that's where we as lawyers should have been intervening. And because there was nobody in the system that cared enough to make the change, it was a classic sort of polytype problem. There was no constituency that was strong enough and loud enough to make that change, and nobody wanted to go out on a limb for this marginalized group.

[01:11:45] Anu Goel: So keeping in with this kind of idea of screening mechanisms, which we've obviously seen evolve, we had a question from one of our classmates, Liam.

[01:11:55] Liam Borque: Hello. What I was going to say is so historically, we have a number of screening mechanisms, both for moral issues like covered by Julia, and for health issues and other safety issues. Ultimately, some of these screening mechanisms, even if they increase the safety, are discriminatory. For example, we discriminate against people from a number of countries of origin, famously the UK for mad cow disease, but the majority of them are developing countries. And the real question is, with today's screening mechanisms, how can we strike the right balance between safety and discrimination?

[01:12:25] Kara Swanson: Yeah. And this is where, as I said, our expertise as lawyers matters. Right. Are we excluding what we can think of as a protected class, an identity prone to be discriminated against? Right. Is this just like the immigration ban where it's nine Muslim majority countries suddenly that are being banned? Or is it people who are from the UK or have traveled to the UK in the 2010s, who, as we don't think of as a class that needs special protection in US law and society? Okay, if it is a protected class, is it narrowly tailored? So you raised the question of the unhoused. So we might think of the unhoused as a group of people who we should have our antenna go up when they're being excluded. Well, what's the purpose of this? The purpose can't be that we're afraid of them because we're dirty and we have this association of dirt and germs and disease. But it might be that it is medically important to be able to contact the provider of a pint of blood. If one of the recipients ends up with a bloodborne disease, that we think that there's something that slipped through the system, that we need to go back and contact the provider and see if the provider needs medical care, among other things. And if somebody's unhoused and we don't have a permanent address, we know we're not going to be able to find them, and that's why we're excluding them. So those are the questions, I think, that we as lawyers should be thinking about, as we think about sort of the ideal regulatory system, using Dennis's example as a worst case, how can we avoid that? But also remembering what happened in the AIDS crisis, I actually started my legal career doing depositions of the families of hemophiliacs who had been affected by HIV and the clotting factor. And it was a huge tragedy, right. That to some extent, for some people, it happened before we had any ability to stop it, right? There were people that were affected and died. So we can't underestimate the consequences of an unsafe blood supply. It's not a trivial thing here. On the other hand, blood is something that if you need it, you need it, right? If you're bleeding out, it can make the difference between life and death. We saw that in Boston with the Boston Marathon bombing. There was a critically injured police officer who survived after getting something like crazy like 13 pints, right? I mean, that really made the difference that they could grab it right there and just start pumping it into him. Thank heavens they could do that. But it would have been horrible if two months later he found out he had HIV, right? That would have not been a good outcome. So we can't trivialize that, but we can also make sure that we're not just enacting our prejudices again, right? We've done it before, but we can try our best not to do it again.

[01:15:30] Mary Beth Bloomer: So, something that myself and other classmates noticed was just how prevalent social norms can be in blood banking, breast milk banking systems. So I was curious in that I feel breastfeeding in general has become a lot less taboo in the United States, at least over recent years. We now have pumping rooms at schools and workplaces. Many large law firms will offer breast milk shipment as part of the package of benefits to their attorneys who are breastfeeding. So, I'm curious to know with what your insight might be as to how modern workplace norms, as well as breastfeeding trends in general, relate back to the historic practice of wet nurses and breast milk banking and what some connections might be.

[01:16:22] Kara Swanson: It warms my heart to see how large American law firms are actually acknowledging that they have attorneys who are breastfeeding and want to continue to breastfeed. When I was practicing law, they put in all new offices and everybody's door was completely glass. And the first thing that we had to do was have them go around and put a modesty screen on the glass up to neck height, because those of us who were pumping in our offices were not really interested in being on display, right? But nobody had thought about that and I'm glad that they are thinking about that. I think that part of what you were asking was about both wet nurses and the possibility of banked human milk to solve that workplace problem. And the big problem with banked breast milk is supply. Unlike any other body product that we're talking about, the population of people who can give, donate breast milk, sell breast milk, is necessarily always very small. Right. It's women who've recently given birth and everybody eventually retires. As one of the milk banks calls. I I have some connection with my local milk bank in New England and the supplies is never there for the babies that need it and they prioritize preemies babies with allergies babies with various digestive issues, right. And they're always rationing and allocating. So I would hope that we continue to live in a world in which they allocate to the six babies and not that really wealthy partners in New York law firms are able to swoop in and buy it and take it away from them. That would be a market solution that I would not appreciate. I have noticed over the past decade or so that there seems to be perhaps more interest among the wealthy in wet nurses. You might not be able to get banked breast milk because they're allocating it, but maybe you can hire a wet nurse to travel around with you. And I think somebody asked the question what might be happening in the future? What kinds of taboo transactions might come back? And if I had to make one prediction, that's one thing that I've been watching and I think it's related to what Marybeth just said, right, that breastfeeding in general is seen as less taboo and is seen as more encouraged. But the idea of cross feeding still has a bit of an ick factor for many people. So this question of if you're babysitting your friend's child and they don't come back in time, can you just suckle them or will your friend absolutely freak out? And of course the answer is extremely personal.

[01:19:18] Anu Goel: So, related to that, one of our classmates, Jenna, had a question.

[01:19:24] Jenna Smith: Hello. In your book, you talk a little bit about the historical disdain that a lot of people had for wet nurses, viewing them as dirty and kind of looking down upon people who chose to feed their children this way. In modern times at least, I liketo think that there's a little bit less judgment over the way that people choose to feed their children. But there's still that idea of breast.

[01:19:46] Anu Goel: Is best among some people looking down on someone who chooses to use formula to feed their child for whatever reason they have for making that decision. Do you think that there's any kind of connection that you see between the modern dislike of formula by some people and the historical disdain for many wet nurses.

[01:20:03] Kara Swanson: I think, Jenna, what you're putting your finger on is that there's a lot of class issues bound up with both the disdain for the wet nurse and attitudes towards breastfeeding. So if we talk about the modern return to breastfeeding, Mary Beth was talking about very privileged women being able to have access to pumping rooms, being able to pump in their offices, being able to pump when they're traveling and ship it back. That is, of course, not available to the vast majority of working women who might want to breastfeed their child when they're returning to work. There's also sort of a reverse class issue, which is that some parents who are capable of breastfeeding deliberately decide not to because they want to separate themselves from that disdain. And really it's what story are they telling themselves, right? That breast is breastfeeding being like a dairy cow instead of a degrading thing, or it unskilled labor, unvalued by keeping you from doing something you want to do, or is breastfeeding empowering life affirming? But again, as I said, that's very personal, right? How you want to interpret that. But Jen is putting her finger on that. It is tied up with the issues of class, tied up with issues of race. A lot of black women are very cognizant of the mammy stereotype and thinking carefully about how they're situating themselves with respect to that, and also in terms know, parental choices about working outside the home or not. And as Jenna says, maybe we would like to think that people are less judgy about that, but go to any playground in America, and I would say that they're probably not.

[01:22:04] Kim Krawiec: Thanks for doing this.

[01:22:05] Kara Swanson: Kara well, thank you all for reading so carefully and asking such good questions. You made me rethink the ways that I had been thinking about this issue in the past, and I'm really excited that you're all going to be lawyers out there in the world that have a good education of this complicated set of issues.