COVID-19 Immunity Passports: Inevitable? Ethical? - A summary of PHEPREN's second webinar.
The recorded seminar is available here
Professor Jeff Kahn - Director and Professor of Bioethics and Public Policy, Berman Institute of Bioethics and Professor in the Bloomberg School of Public Health, Johns Hopkins University
Dr Sylvie Briand - Director, Global Infectious Hazard Preparedness, World Health Organization, Geneva
Professor Samia Hurst - Professor of Bioethics, Geneva University Medical School
Dr Voo Teck Chuan - Centre for Biomedical Ethics, Yong Loo Lin School of Medicine, National University of Singapore
Immunity passports are seen by many as a tool to facilitate the easing of restrictive measures and a return to relative normality in lieu of a vaccine. In response to significant media and policy interest in this topic, PHEPREN's second webinar addressed the feasibility and ethical considerations raised by such documents.
The rate at which we have acquired knowledge about COVID-19 is astonishing; however, much remains uncertain, including the state of evidence concerning immune response to SARS-CoV-2, the virus that causes COVID-19. Dr Sylvie Briand explained how immune response works, evidence about immunity to coronaviruses in general, and antibody responses to SARS-CoV-2 in particular. She highlighted the need for more time to properly assess serologic testing before using it as a basis for issuing immunity passports. Sylvie then outlined examples where similar documents have been used in the context of Ebola and Yellow Fever. While the examples demonstrate immunity passports could be useful from social, travel or trade perspectives, there have also been problems with corruption, counterfeiting and stigma which need to be taken into account.
Professor Samia Hurst reiterated that the viability of immunity passports depends on how robust the science is. Even if sufficient certainty of immunity is possible, individuals making informed decisions based on their results is very different from their being used as a basis for giving or withholding rights from individuals. Immunity passports will create a vast difference in the rights, privileges and obligations of individuals, and this requires justification. Moreover, guaranteeing sufficiently equal rights for all would necessitate substantial and rapid reorganisation of society so nonimmune individuals can exercise their rights and make meaningful choices. Such reorganization would negate much of the usefulness of immunity passports. Other considerations include the duration and legal basis; protection of data and privacy; whether confidentiality is possible when people’s public behaviour will reflect their immune status; and that inequalities will undermine solidarity.
As some countries will probably introduce immunity passports, Dr Voo Teck Chuan advocated a pragmatic approach to facilitate ethical implementation. High stakes and uncertainty make the precautionary principle useful in minimising harms while further evidence is collected and evaluated. Policy-makers must act to mitigate harms, but some are unintended and harder to discern. For instance, digital technologies may enable greater freedom of movement, but legislation is required to protect privacy and prevent misuse of data. Nor are they feasible in all settings, where a digital divide could exacerbate disadvantage. He agreed that a baseline of equality and rights should be guaranteed, but where mass testing is not possible, the introduction of immunity passports could cause uneven distribution of benefits according to people’s access to testing and capacity to pay for it. Potential benefits are that governments could focus financial support on those unable to resume work, and in case of vaccine scarcity, collective protection could be maximized by prioritizing nonimmune individuals. By promoting collective benefits, the welfare of society's most disadvantaged, and fair distribution of benefits and burdens, we can lift people up rather than levelling down.
Professor Jeff Kahn highlighted the political context of this debate. Leaders are under intense pressure to help people return to a more normal life. He then raised the following questions:
· Passports are associated with crossing borders. Is passport the right word to use? How would immunity passports work in terms of transnational travel?
· Even if we attempt to ensure a level of equal protection of rights, there will likely be an incentive to be exposed and granted a license/passport with its associated privileges. What social justice implications and perverse incentives are raised by immunity passports?
· What about obligations? When so many people are out of work and suffering, what obligation is there for people to use their immunity for good?
· Is international guidance or coordination needed?
· What are the implications for LMICs?
A selection of thoughts shared in response:
· A perverse incentive to disobey public health orders through deliberate infection undermines response efforts by punishing compliance and puts further strain on health care resources. How to prevent this? All else being equal, do people have a right to get infected?
· On obligations, understanding the risk of individual health care workers could aid allocation of PPE or staff to duties associated with higher risk of infection, assuming surety in scientific evidence of immunity. However, conscription could undermine solidarity.
· International guidance is needed to help countries avoid major mistakes in implementation. Basic ethical considerations must be made explicit to safeguard people’s rights and welfare in the diverse political, legal and social contexts they may be applied to.
· Any implications for travel require international coordination because the International Health Regulations and its justification criteria for additional measures must be considered.
· Harmonising criteria for issuing documents might lessen the likelihood of infection spreading globally from places with poor oversight mechanisms.
· Existing inequalities people experience due to the nationality of their passports could be exacerbated, so fair distribution of quality tests should be a priority.
Questions from listeners included:
· whether the ethical justification is stronger if reserved for health workers or those working with vulnerable communities, and if a related imperative to disclose immune status exists;
· how to balance the interests of immune/nonimmune in countries lacking basic human rights;
· how a cost-benefit analysis would look;
· whether corruption would increase;
· repercussions for the insurance industry.
Additional resources in the Epidemics Ethics database
All resources on this topic can be found by searching for "immunity passports & certificates". WHO has produced a scientific note on immunity passports which is useful for understanding the current scientific evidence available. The database has resources from Dr Voo Teck Chuan, Professor Samia Hurst & Professor Jeff Kahn. Others mentioned during the seminar were Baylis & Kofler, the Edmond J. Safra Center for Ethics & the International Health Regulations (2005). Additional articles include Phelan on immunity passports, human rights, equity and the law & Persad & Emanuel on the ethics of immunity-based licenses.
Continuing the conversation
We welcome you to continue this discussion in the comments section below. In addition, if there are other relevant resources you would like to share, please note these in your comments or submit the resource so our team can add it to the Epidemics Ethics database.