In the early spring of 2020, when the heart-sinking reality of the COVID-19 pandemic was coming into focus around the world, an old and controversial idea found its way into public consciousness: immunity passports.
These documents would certify that the passport-holder had mounted a positive immune response to the virus and was presumed to be resistant to further infection. Passport-holders might safely be released from public health restrictions and allowed to return to work or study, and to live a more normal everyday existence.
After a period of intense attention, however, the idea of dividing populations into two groups with radically different privileges proved too contentious and had moral implications. No western government ended up implementing a system of immunity certification, though some are now looking again at the idea, even though immunity certificates have been rejected by many experts.
We need to rethink the idea. Some of the reasons that were good reasons to resist immunity passports in the spring are no longer valid — and some of them never were good reasons. More pressingly, we no longer have much of a choice as data shows workplace spread is rampant and won’t be curtailed by lockdowns since many big employers, like Walmart and Amazon, are exempt.
In the next few months, the proportion of the population that has presumed immunity to COVID-19 will go up. This is both because of better and more widespread testing for immunity, and also because more and more people will be vaccinated.
But how we will treat the growing class of those who have been vaccinated compared to those who have not?
It will be important to have a clear and principled rationale about any new privileges we extend to those who are immune so that their actions don’t harm the ongoing public health response to the pandemic.
People who have either tested positive for an immune response to the COVID-19 virus or who have been vaccinated will probably chafe against ongoing and seemingly unnecessary restrictions on their activity. Private entities like businesses and entertainment venues will have strong incentives to establish their own practices for treating employees or customers differently if they produce some sort of evidence of immunity.
So people who are immune will inevitably act and be treated differently than those who are not, regardless of whether our governments and health authorities intend them to be. We need to think as a society about what that means.
Why the controversy over proof of immunity?
Three types of objection have been raised against immunity passports:
They’re immoral or illegal.
They’ll contribute to further inequity.
All three require careful consideration.
The first worry is that immunity certificates will make the pandemic worse, either because the testing they depend on is inaccurate or because giving out certificates will encourage risky behaviours. Inaccurate testing, in fact, was a major concern in the spring, to the extent that the World Health Organization recommended against implementing immunity passports for this reason.
But since then, antibody tests have become significantly more accurate (though far from perfect) because the tests themselves have improved and because as levels of immunity go up in the population, the positive predictive value of the tests increases.
Concerns about what are known as perverse incentives have also dissipated compared to six months ago. The worry was that people might be rewarded for risky behaviour if those who caught and recovered from COVID-19 were given privileges that others do not have.
The second worry is that it’s not morally or legally appropriate to divide a population into two classes, one more privileged than the other. But even though many forms of discrimination are immoral and unacceptable, not all of them are. This sort of discrimination, unlike racism for example, makes a real difference to public safety. And it’s possible the divisions would be temporary, lasting only until there’s widespread immunity.
What’s more, there’s a public health ethics principle — “least restrictive intervention” — that might be violated by continuing to impose restrictions on people who are immune.
The third concern is that immunity passports might make existing inequities much worse. The pandemic already affects disadvantaged groups, like women, people of colour and the poor more than others.
Adding another significant level of privilege in the form of immunity passports historically could benefit those who are already advantaged more than those who are not, worsening inequalities. This requires controlling access to the vaccine carefully so it’s determined by need rather than social privilege.
Another worry is that immunity passports will require monitoring to certify them and to check their validity every time they’re used to do something those without passports cannot do. Such a system of pervasive social monitoring raises its own concerns about surveillance and privacy.
What should immunity certificates look like?
All of these concerns underscore why we must consider the best system for immunity certification, with inaction not an option. But some difficult questions remain.
Although people who are vaccinated or have recovered from the disease are likely to be immune from infection, it is unclear whether they could still infect other people.
So it may be more appropriate that people with immunity passports are allowed to do things that would otherwise have put themselves at risk of infection — such as commuting to a workplace — than permit them to do things that could put others at risk.
So even the immune-certified should probably continue wearing masks and physically distancing in public for now, in case they could infect others.
Immunity certification will carry benefits, both to the passport-holder and to those who depend on their services, but it will also be important to be clear about what demands are placed on passport-holders.
Should employers be able to require them to return to the office, for example? Could certain essential workers, such as nurses or teachers, be mandated to be vaccinated?
This compels us to balance factors such as individual autonomy, the common good and the delicate task of managing the vaccine rollout so that as many people as possible get their shots.
Avoiding worsening inequities
Finally, since immunity certification will carry benefits and responsibilities, it will be vital to ensure that existing patterns of disadvantage are not replicated or worsened.
To give one example, low-income people will need no-cost access to vaccinations, and this should include reducing or offsetting travel costs if they have to get to an inconvenient vaccination location and unpaid time off work.
We should also try to ensure that those in precarious employment are not pressured to vaccinate and return to workplaces more than white-collar employees.
This will be difficult, and that’s why it’s imperative that we figure this all out now, as a society, and not leave it to the whims and demands of private businesses and citizens.