By Alberto Giubilini (University of Oxford) and

Jay Bhattacharya (Stanford University)

 

crosspost with Lockdown Sceptics

 

[Prof Jay Bhattacharya (Professor of Medicine, Stanford University) and I collaborate on Collateral Global, a new project that aims to evaluate the impact of lockdowns and other pandemic restrictions. We have the same view on lockdown and pandemic restrictions, but we do have our own internal, healthy disagreement. Most people who are skeptical and critical of lockdowns (as both Prof Bhattacharya and I are) are also against immunity passports (as he is), often for the same reasons. I disagree on this point and I think some form of immunity passport should be introduced. In this exchange published on Lockdown Sceptics, we try to explore exactly where our disagreement lies and try to identify possible areas of agreement on the matter. AG]

 

The Case For Immunity Passports

by Alberto Giubilini

Having read the excellent piece in the Wall St Journal by Prof. Bhattacharya and Prof. Kulldorff, I have the impression that they take many of the reasons against lockdowns to also be reasons against immunity passports. Among these, individual liberty is prominent.

I disagree.

I think the importance of individual liberty is actually one reason in favour of some form of COVID-19 immunity passport (this does not necessarily mean we should apply the requirement to the whole population).

I say ‘immunity’ passport, not ‘vaccination’ passport, because the relevant factor for me is the reduction of the risk of transmitting the virus to vulnerable people by acquiring some level of immunity, regardless of whether the immunity comes from having caught the virus or having been vaccinated.

There are many people among the most vulnerable to COVID-19 who cannot be vaccinated for medical reasons. These would be exempted from passport requirements – medical exemptions are normally applied where vaccine mandates are in place. Besides, there are many people in the most vulnerable groups who, even if they have been vaccinated, are not protected, given that vaccines are not 100% effective. We need to maximize the chances of protecting these people as far as is reasonably possible. (Which excludes lockdown. These are unreasonable measures.)

Their freedom to have a normal life, to travel, to go to public spaces, to socialise – in other words, their fundamental freedoms (the very same ones that lockdown denies) – presuppose that they are able do all these things as safely as possible. If I am an unvaccinated vulnerable person and I have reason to think very few people in my local pub or in my community are vaccinated, in an important sense I am not free to go to the pub or to the shops. (I would only be free in a legal sense, but that is not the kind of freedom that matters the most.) Doing that would mean taking on quite a large risk (I am in a vulnerable group after all), and that would be true even if I am vaccinated (vaccines are not 100% effective, after all).

Because my liberty matters and arguably the state has a responsibility to protect it as much as is reasonably possible, I can reasonably expect some safeguards to be in place to guarantee that it is safe for me to do all these things.

An immunity passport scheme can offer some extra level of protection to vulnerable people by significantly reducing the chances of transmission without all the costs of lockdown. Vaccines might not be as effective at preventing transmission as they are at preventing disease, but even a reduction of risk can be important.

The two main ethical objections Prof. Bhattacharya and Prof. Kulldorff raise against immunity passports are that they would be discriminatory and they would infringe upon people’s liberty.

I agree there is a problem with unfair discrimination if we introduce passports while not everyone (or everyone whom we want to apply passport requirements to) has been offered a vaccine. But this is only a temporary problem. Some countries (including the U.K. and the U.S.) are proceeding very quickly with vaccine roll outs. So we might either tolerate some unfairness for a few weeks or months, or wait a few months before introducing passport requirements. The level of unfairness would be vastly reduced if passports were issued not only on the basis of vaccination status, but also on the basis of naturally-acquired immunity (which would also prevent wasting scarce vaccine doses on those who already had Covid).

When everyone has been offered a vaccine, then the real ethical issue is no longer about discrimination, but about freedom of choice. Since there would be a cost associated with vaccine refusal (e.g. you’re not allowed into the pub, unless you have naturally acquired immunity), then the choice of whether or not to be vaccinated would not be free in an important sense.

So here we are back to the same principle: individual liberty.

Immunity passports present a clash between two liberties: the basic liberty of vulnerable people to have a normal life (with all its basic freedoms that lockdowns have taken away from all of us) versus the liberty of some people to refuse the vaccine. It seems the case against immunity passports is based on prioritising the latter, but I don’t see why we should do that.

To adjudicate the matter we need to consider a broader range of values in addition to liberty. These include harm prevention and fairness. If we need to sacrifice one of two liberties (having a normal life with its basic freedoms versus refusing the vaccine), I think we should aim at minimising the harm involved in the infringement. The harm of being vaccinated is vastly smaller than the harm of giving up a normal life by the vulnerable. Fairness might also require that everyone makes their contribution towards making public spaces as safe as possible, when this entails a very small cost to individuals.

Ultimately, immunity passports would infringe liberty, yes, but so would the failure to introduce them. It is a question of whose liberty and which kinds of liberties to sacrifice. It seems we just need to go for the lesser of two evils.

Alberto Giubilini is Senior Research Fellow, Faculty of Philosophy at the University of Oxford

 

The Case Against Immunity Passports

by Jay Bhattacharya

Before I address the substance of Dr. Alberto Giubilini’s interesting essay in support of immunity passports, I want to thank Dr. Giubilini and Toby Young for inviting me to debate this topic. One of the casualties of the pandemic has been opportunities to discuss issues civilly and arrive either at agreement or a better understanding of the substantive reasons for disagreement.

In the spirit of a fair debate, I will upfront restate my understanding of Dr. Giubilini’s case for immunity passports so that we are both working from the same premises. Here is my account of his argument: Immunity passports enable people who – for medical reasons – cannot be vaccinated to participate in society with a minimum of worry of being infected. The passports expand liberty for such people since they would not participate in society for fear of being infected. Against this should be weighed the violated liberty of people who do not want to be vaccinated for non-medical reasons and would effectively be coerced into vaccination by immunity passports. When Dr. Giubilini weighs these two competing interests, he judges the expansion in liberty for the medically non-vaccinated worth the limitation in liberty for the non-medically non-vaccinated.

While I admire where Dr. Giubilini’s heart is on this question – to protect the vulnerable against avoidable risk of Covid infection – I am unconvinced that the argument is a sufficient basis for the proposition that immunity passports would promote the social good. Let me first provide the premises on which I am basing my argument, which I believe we both accept.

 

Predicates for the Argument – Focused Protection Rather than Lockdown and No Vaccine Shortage

My view on why focused protection of the vulnerable and lifting lockdowns would be the best course is well known, and I will not belabour that point here. In what remains, I will take it as given that we agree that once focused protection of the vulnerable is achieved, no lockdowns restrictions are necessary. My argument will undoubtedly not convince the zero-Covid folk who think that all social goals should be put to one side until Covid disappears. But I suspect such people would favour an extensive range of draconian lockdown restrictions that neither Dr. Giubilini nor I think justifiable. Their arguments in favour of vaccine passports are just a special case of their support for lockdown. Thus, there is no need to address their views here since I have made my general case against lockdown in many other places.

One should also distinguish the case where the vaccines are in short supply versus the case where there are sufficient doses available to vaccinate everyone, as is true in the U.S., U.K., Israel, and a few other countries. In the former case, I think Dr. Giubilini and I agree that a vaccine passport system is unethical since it would discriminate against people who have been unable to procure a jab. So I will focus on the latter case of sufficient vaccine supply since that is the only situation where there is a disagreement between us.

Public Health Problems Caused by Immunity Passports

Though the liberty issues emphasised by Dr. Giubilini are important, in my view, the central problem with immunity passports is that they are bad for public health.

Vaccine hesitancy among those most susceptible to severe outcomes after Covid infection (primarily the elderly) is the key public health problem at this point in the epidemic. Age is the most important risk factor for severe Covid infection outcomes; there is a thousand-fold difference between the mortality risk faced by the oldest individuals and the youngest after infection. A comprehensive meta-analysis of seroprevalence studies published in the Bulletin of the World Health Organization finds that people aged 70 and over have a 95% infection survival rate. In comparison, people under 70 have a 99.95% infection survival rate.

In the U.S., more than 80% of the elderly population has already received one vaccine dose (of the two shot regimens), and 70% are fully vaccinated. It has been difficult for states to move that fraction higher for various reasons, but perceived doubts about the vaccine’s safety features prominently among the explanation. While the adenovirus vaccines have triggered a safety signal in younger populations that have led regulatory agencies to issue black box warnings, there have been no safety problems established for these vaccines in the older population. But the issue is one of perceived safety rather than actual safety.

To that specific population that is already largely distrustful of public health authorities (and with much good reason given their manifest failures during this pandemic), the imposition of immunity passports will have the paradoxical effect of reducing vaccine demand. A certain kind of person, over-represented in the vaccine-hesitant group, will respond to an immunity passport requirement by wondering why, if the vaccine is so great, public health authorities and businesses are coercing him to get it? I confess that I have had this thought, even though I have read the vaccine trial data closely, think that the vaccines are great, recommended vaccination strongly to my older friends and family members, and am fully vaccinated myself. Worse, there is the distinct possibility that the distrust of public health created by Covid immunity passports will foster further erosion of the popular support for other vaccines such as the MMR vaccine that protects against measles, mumps, and rubella. If this occurs, it would be a disaster from a public health perspective.

Requiring immunity passports in the U.S. and U.K. would provide incentives to non-vulnerable people to jump the queue in places around the world where there is still a vaccine shortage. If the passports are a condition for flying to the U.S. or the U.K., affluent younger people living in places with shortages, who travel to the U.S. or U.K. for business or pleasure, would have an incentive to take vaccine doses that would better go the vulnerable older people living in these countries. The net result would be bad for global public health as vulnerable people would spend a longer time unvaccinated and at risk of poor Covid outcomes.

Immunity Passports Do Not Protect the Vulnerable (Much)

Now that I have made my case, I turn next to discuss Dr. Giubilini’s argument. I think there is some force in it, though the situation is more complicated than his essay allows. Those complications imply that immunity passports will not protect the medically non-vaccinated much.

First, the absolute reduction in Covid infection risk for the medically unvaccinated from an immunity passport scheme is likely to be small. The long-run environment in which the immunity passports will be implemented will be one of herd immunity, with a large fraction of the population immune due to natural infection or the vaccine. While immune people may still be asymptomatically infected and pass on the virus to others, the probability of such an event is vanishingly small. So we need only consider the unvaccinated. The virus will not be gone but will be endemic in the population, with case rates substantially lower than we have grown used to this past pandemic year. A random interaction between two unvaccinated people in this endemic equilibrium state will be much less likely to result in disease transmission than during the height of the epidemic since it will be less likely that either is infected. Immunity passports will thus take a small risk and reduce it by a very modest amount. The unvaccinated will still need to be more careful about their exposures during the Covid high season, whether there is a vaccine passport or not.

Second, for many people for whom there is a true medical indication against Covid vaccination, it’s likely that Covid is not the only infectious disease that threatens their health. Suppose, for instance, we learn at some point that immune-compromised patients should not get the Covid vaccine. (The vaccine trials did not include enough immune-compromised patients to say much about this topic.) A Covid immunity passport requirement would not increase their liberty since they would not frequent those locations requiring immunity passports anyway to avoid other non-Covid infections.

Third, Dr. Giubilini envisions an outcome where immunity passports will permit medically non-vaccinated people to engage safely in society, knowing that they are shopping and interacting primarily with vaccinated people when they enter businesses or go to work. But the distinction between medically non-vaccinated and non-medically non-vaccinated is not clear. While there is a lot of evidence about the vaccine’s safety available, we are far from a comprehensive knowledge of the set of people for whom a vaccine is medically not indicated. In the meantime, there will be many who claim a medical exemption who could probably safely take the vaccine. There are also people – such as people with good faith religious objections to the vaccines – that I think should be exempt from the passport scheme. Just like those with medical contraindications to vaccination, they suffer great harm from being vaccinated, though of a spiritual rather than physical nature. Suppose the set of people who receive medical and non-medical exemptions from passports is large. In that case, even places that require a passport will include many unvaccinated people, so the reduction in Covid risk will be slight.

Finally, another complication has to do with how the market copes with discriminatory requirements like immunity passports. If immunity passports are legal, my prediction is that within many industries, some businesses will exclude those without a passport, while a second group will provide segregated areas in the fashion that smokers and non-smokers were commonly segregated in restaurants not too long ago. If this is indeed the equilibrium, then even if passports are legal, many businesses would permit non-vaccinated individuals to enter. The medically non-vaccinated would be in the same position they would be without passports as far as those businesses are concerned. That is, they could choose to enter and mingle on the premises with unvaccinated individuals or not choose to enter. The passport would not increase their liberty in the sense Dr. Giubilini means.

Weighing Liberty and Public Health

There is not sufficient space here in this short essay to weigh definitively the public health considerations that I raise here against the concerns of liberty that Dr. Giubilini raises in his essay. The issues are complicated, as the public health problems caused by immunity passports can themselves impinge on the liberty of the people harmed. There are also important distributional issues involved, as less affluent and minority populations are overrepresented among the vaccine-hesitant. Readers may weigh these factors differently than I do, and of course, I cannot argue people out of the values they hold. I suspect, though, that many will agree with me that the public health harms from immunity passports are not worth it, even if they marginally impinge on the liberty of the medically non-vaccinated group that drives Dr. Giubilini’s thinking.

Jay Bhattacharya is Professor of Medicine at Stanford University

 

Concluding Remarks

by Alberto Giubilini

I am grateful to Prof. Bhattacharya for this interesting exchange and to Toby Young for hosting this debate on Lockdown Sceptics. I think one useful way to wrap this up is to identify areas of agreement and disagreement.

This is probably more useful than responding point by point to Prof. Bhattacharya’s considerations: identifying what exactly disagreement is based on and what common ground is there can help move the debate forward.

I find myself in the unusual position of being both against lockdown and other severe restrictions and in favour of some form of immunity passports. (I am simplifying for the sake of brevity: both stances are more nuanced than this brief description suggests.) Readers of LS would obviously agree with me on the former stance but I am well aware they would strongly disagree with me on the latter. Identifying the nature of disagreement on immunity passports with one of the most prominent opponents of lockdown might help us see better why we hold the positions and beliefs that we do. This is itself a form of progress.

What I have said so far is related to the first point of agreement with Prof. Bhattacharya: the opportunity for rational and civil discussion around pandemic measures has been one of the casualties of the pandemic. This is sad but perhaps not surprising, as it is line with the more general suppression of academic freedom we are witnessing in other areas of academic debates. It is both depressing – because it contradicts the very nature of academia – and dangerous – because by suppressing dissenting voices we might miss relevant facts and considerations that could result in better policies.

Moving to more specific issues pertaining to immunity passports, I agree with Prof. Bhattacharya that the presence of herd immunity would significantly weaken, if not completely defuse, the ethical case for immunity passports. The core of my argument is the concern for the safety – and therefore the liberty – of those who, even after full vaccine roll outs, remain vulnerable to COVID-19, either because they cannot be vaccinated for medical reasons or because vaccines are not effective for them. Thus, once vulnerability is removed or sufficiently reduced thanks to herd immunity, there is no reason to require proof of immunity when engaging in normal interaction with other people.

I assume that we would need to be sufficiently confident that, without immunity passport requirements at least for entry into a country (forget about passports for pubs for the moment), herd immunity in that country could be preserved over time. A large number of people entering a country in which immunity is waning quickly might find the vulnerable people in that community ‘off guard’, even if vaccinated. If there was a system in place that could give enough reassurance that this would not happen, then I agree with Prof. Bhattacharya that we should not have passports. If we could not have such reassurance, I would disagree. This is largely an empirical issue, rather than an ethical one.

Another point of disagreement is – I suppose – whether we should have immunity passports while we move towards herd immunity.

This would presumably be a transitioning phase where not everyone has been offered a vaccine. I agree with Prof. Bhattacharya that immunity passports in this situation would be unfairly discriminatory towards those who have not been offered the vaccine yet. I am not sure they would be all things considered unethical – maybe some unfairness is a price worth paying if it is for a short period of time and if it brings about significantly large benefits to the vulnerable (in terms of protection from COVID-19) and to the economy. But I am agnostic on this point: it would largely depend on how long this unfair phase would last and what the actual benefits would be. Again, this is a largely a matter of empirical, rather than ethical considerations.

So far, we have identified two points of potential disagreement – on whether we should have immunity passport in case where we can’t have some reassurance that herd immunity will be preserved, and on whether we should have immunity passports while we move towards herd immunity. Interestingly, they hinge more on empirical considerations than on ethical ones. This is important because it means that disputes around immunity passports might be resolved by establishing facts or realistic predictions about immunity, rather than by sorting out some more fundamental ethical disagreement about the relative importance of liberty and the public good.

Another point of disagreement is, once again, around an empirical, rather than an ethical point: Prof. Bhattacharya is concerned that making vaccines mandatory in the form of passport requirements would erode people’s trust and therefore result in lower vaccine uptake. This might or might not happen. There have been cases in the past in which the introduction of vaccine mandates increased vaccine uptake – for example when the MMR vaccine was made mandatory for school age children in Italy. Often hesitancy is defeated precisely through the introduction of mandates that create social norms where people are initially unwilling to comply. This happened for example with car seat belt mandates: they were met with a lot of resistance initially, but now using seat belts is a social norm and most people would probably buckle up even if there was no legal requirement. I am not saying that this will happen in the case of the COVID-19 vaccine. I genuinely don’t know. My disagreement here is on the strength that this consideration should have in the economy of the argument against passports. I grant passports might result in lower vaccine uptake, and if we have good reasons to think this will happen, I agree we should not introduce them. But the opposite might happen as well, and probably different communities would react differently to the introduction of passports. Again, we would need to establish what a realistic prediction would be in different contexts.

Finally, another point of disagreement is about non-medical exemptions, including religious ones. I disagree with Prof. Bhattacharya that religious opposition to vaccines constitutes a good enough reason for exemptions from vaccine mandates, if exemptions pose risks to other people. (Indeed, some U.S. states are removing non-medical exemptions from vaccine mandates for children’s enrolment in state schools.) This point is very complex and would require its own discussion for which we do not have space here. But for the purpose of the present discussion, it is important to identify this as an area of disagreement. Once again, this is in itself good, because we have now identified another issue we should be focusing on when debating the pros and cons of immunity passports: the tension between freedom of conscience (either religious or secular) and public health, if such a tension actually exists. I suppose this is a point where people with different political or ethical views would reasonably disagree. So in this case the disagreement is more genuinely ethical, rather than empirical.

More could be said about many points we have both raised, but time and space constraints do not allow it. One concern I have is that most people who (rightly, in my view) oppose lockdowns automatically apply (wrongly, in my view) the same arguments to immunity passport. I think this is not so straightforward, and I hope this exchange has led a few people to at least question whether the two arguments automatically go together. I am very grateful to Prof. Bhattacharya and to Toby Young for the opportunity to discuss this issue here, especially since they both disagree with me on this matter. I hope this will help us all, if not to resolve our disagreements, at least to disagree better.