'Immunity passports' could help against pandemic – or harm society

Why We Wrote This

As the coronavirus works its way through the population, it should be leaving survivors who are immune to reinfection in its wake. Some have proposed capitalizing on their immunity – but that could open an ethical quagmire.

Francisco Seco/AP
Passengers like these, at the Zaventem Airport in Brussels on June 15, 2020, could enjoy an easier trip if proposals to implement an "immunity passport" system are realized. But ethicists warn that the system could bring additional burdens along with its utility.

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If COVID-19 behaves like other diseases, at least some portion of those who have fought it off should now have an immunity against contracting it again. Which means there should be hundreds of thousands, if not millions, of people who ought to be capable of returning to normal life without putting themselves or others at risk.

Medical researchers and tech companies propose taking advantage of that population, by granting them “immunity passports” which would allow them to bypass restrictions. But ethicists warn that granting special status to those who are immune opens up moral questions about obligations that might follow.

“I shouldn’t have to stay in my home and socially distance and not go to my office if I’m immune from infection. That doesn’t make any sense,” says Jeffrey Kahn of the Johns Hopkins Berman Institute of Bioethics. But “it’s not just freedom but rather what responsibilities might be imposed on the individual. ... An employer could say, well you’re immune, so now you should work in this area that you didn’t before because we need people in this essential area and you are immune and safe.”

Europe, like many places around the world, is in the process of reopening after several months of lockdown to control the spread of the coronavirus. But even if that reopening goes well, society will not return to the way it was. The threat of a new outbreak persists – as shown by Germany’s recent flare-ups – meaning that countries will have to operate under strict preventive measures.

But some argue that needn’t be true for everyone.

If COVID-19 behaves like other diseases, at least some portion of those who have fought it off should now have an immunity against contracting it again, they point out. Which means there should be hundreds of thousands, if not millions, of people who ought to be capable of returning to normal life without putting themselves or others at risk.

Medical researchers and tech companies propose taking advantage of that population, by identifying them and granting them special privilege in the form of “immunity passports” – digital or physical documents that would be issued to those who successfully recovered. Those so equipped could bypass restrictions imposed on others still at risk of contracting the novel coronavirus, enabling them to help restart the economy and society safely.

Editor’s note: As a public service, all our coronavirus coverage is free. No paywall.

In the absence of a vaccine – and assuming that there is long-lasting immunity from the virus – advocates argue that immunity status could influence the allocation of human resources in pandemic response efforts and help hard-hit communities. While no silver bullet, such a solution, which dodges draconian lockdowns and the devastating toll these take on the economy and mental health, appeals to many.

“It doesn’t make sense to have a one-size-fits-all approach if there are specific characteristics of individuals that matter for what kinds of precautions they should take,” says Jeffrey Kahn, director of the Johns Hopkins Berman Institute of Bioethics. “I shouldn’t have to stay in my home and socially distance and not go to my office if I’m immune from infection. That doesn’t make any sense.”

But even if surviving COVID-19 confers some kind of immunity – a relatively reasonable assumption – experts say that significant scientific and logistical challenges must be overcome before passports are seriously considered. And on the ethical front, a scenario where most of the population lacks immunity raises questions on how and whether to accommodate – or burden – the immune.

“It’s not just freedom but rather what responsibilities might be imposed on the individual,” notes Dr. Kahn. “So an employer could say, well you’re immune, so now you should work in this area that you didn’t before because we need people in this essential area and you are immune and safe.”

A tool for safely rallying volunteers?

Governments around the world, including Chile, Switzerland, Italy, Germany, and the United Kingdom, are considering the ethical and practical implications of immunity passports. Banking on a future where digital immunity certificates are accepted, tech companies are crafting cutting-edge solutions. These range from phone apps to portable devises based on QR codes, blockchain technology, and facial recognition.

But uncertainty over the presence and duration of immunity, unreliable testing, and the generally low prevalence of the virus limit their potential. The World Health Organization has cautioned against immunity passport initiatives, stating there is no proven link between recovery from the disease and immunity. And science aside, serious questions remain over who would have the authority to issue such health passports and how they would be certified and standardized to allow for their international application.

Much depends on what governments are trying to achieve with their public health strategy. “Immunity passports should be stopgap measures until a vaccine is developed,” says Teck Chuan Voo of the Centre for Biomedical Ethics at the National University of Singapore. “You should not think of them as a permanent solution.”

Immunity passports, he points out, could be used quite narrowly. They could be used to mobilize volunteers who are immune to COVID-19 to help or test people in elderly homes or migrant communities that have been seriously afflicted by the virus. Immunity status could shape an individual’s decision to wear masks, or help determine who can access education facilities and work places without putting others in danger. The risk is such solutions become permanent if no vaccine is developed. They could create stigma or a negative incentive to contract the disease.

A major widely shared concern for ethicists is the prospect of creating a two-tier system of society where key rights, and on the flip side responsibilities, are determined by immunity status. Much depends on how many people in the population actually have antibodies that could be protective against the virus. If it is only a small number, then immunity certificates won’t help restart strategic businesses or economic sectors at scale, notes Dr. Kahn. The prevalence of the virus in most countries with reliable data is below 10%.

“The fear is that if you were to allow immunity certificates, then only people who could pay for it, who could access it, might be able to return to all these benefits including international travel, while the rest of the population might be stagnating until a vaccine is developed,” says Dr. Voo, adding governments may need to consider compensatory benefits for those who not immune. “You still need to look for other strategies to allow people to transit to normal functioning and normal life.”

Daniel Cole/AP
French gendarmes approach a car on the Franco-Italian border in Menton, France, June 15, 2020. Border checks could be facilitated by immunity passports, by allowing carriers to bypass mandated quarantine periods.

Or a greater burden on minorities?

Others worry immunity passports could pave the way for dystopian and deeply undemocratic societies – akin to that depicted in “The Handmaid’s Tale” by Canadian author Margaret Atwood.

“It is concerning for us as a society to establish an entirely new biological line by which we are going to decide the haves and have-nots, i.e. the immuno-privileged and the immuno-deprived,” says molecular biologist and bioethicist Natalie Kofler. “We know from history and all sorts of situations that when we start dividing society in those ways, it causes great harm to society as a whole, as well as to the individuals.”

She points to the experience of New Orleans prior to the Civil War. Immunity from yellow fever, a mosquito-borne disease that killed about half of those who caught it, was taken by the local community as a sign of “acclimatization” to the city at a time of high migrant arrivals. Parents wanted their children to marry survivors and politicians touted overcoming the disease as a badge of honor. The erroneous assumption that individuals of African descent were more resilient to yellow fever was used to justify slavery.

Fast-forward two centuries and similar scenarios are playing out again, she notes. Privileged, generally white people get to stay in the safety of their homes while low-income people, often ethnic minorities, were out on the front lines working throughout the pandemic. The possibility of front-line workers contracting the virus is greater than those who stayed home. By giving them immunity passports, the burden of what should be a collective responsibility to fight the pandemic disproportionately falls on them.

“If the motivation for immunity passports is to restart an economy, [then] those who are unemployed or underemployed, those who are elderly, children, those who may have physical or mental disabilities are certainly going be last in line for this scarce resource,” says Dr. Kofler, a lecturer at the Harvard Biomedical Ethics Center. “And secondly, if you then layer on racial inequity, which is a huge issue in most countries of the world and in particular the U.S., people of color are going to be last in line.”

She also has serious concerns over racial dynamics when it comes to access to testing and monitoring. Texas testing sites for the COVID-19 virus were concentrated in predominantly white neighborhoods. Stop-and-frisk laws in the United States and Canada disproportionately impact people of color, so she says it is easy to imagine police focusing on these groups if empowered to check the immunity status of people on the go.

“At the end of the day, we just don’t know enough about how COVID-19 immunity works,” warns Dr. Kofler. “If any government is actually dedicated to evidence-based policy, it would be just the height of folly to build a policy around something like this where we still have so much uncertainty.”

Editor’s note: As a public service, all our coronavirus coverage is free. No paywall.

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