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Thanks to @JAMA_current for publishing my “The Ethics of COVID-19 Immunity-Based Licenses (‘Immunity Passports’)” (w/Zeke Emanuel) https://jamanetwork.com/journals/jama/fullarticle/2765836 The piece is short—trimmed a lot from 1st draft—& open access, so hopefully easy to read. Thread to emphasize a few points /1
Ethical problems with immunity licenses—or other tailored public health policies—must be compared to the #bioethics problems with universal restrictions, or abandonment of restrictions, which both produce serious harms and inequalities. Not to a world without #Covid19. /2
Driver’s licenses—not passports—are the best analog for #Covid19 immunity certifications. They are tailored to the risks of a vehicle & driver. Would an objection to immunity licenses also apply to driver’s licenses? If so, it justifies better implementation, not rejection. /3
Just as you don’t need a CDL to drive a car, immunity licenses would be relevant for specific, risky activities, like working w/vulnerable patients or going to high-risk, nonessential businesses. They wouldn’t justify banning unlicensed people from work or keeping them inside. /4
The #publichealth principle of the “least restrictive alternative” also supports immunity licenses. https://bioethics.georgetown.edu/2015/03/using-the-least-restrictive-limits-in-public-health-emergencies/ Current stay-home orders are justified b/c of risk of harm to self & others from Covid-19, but not as applied to people at little or no risk of infection./5
We also identify other ethical values supporting immunity licenses—reduced unemployment & isolation, increased safety for vulnerable patients, and the use of relevant medical evidence rather than assumptions about immunity and vulnerability. /6
Does all this mean we should rush to immunity licenses? No, and we identify several challenges. But these are scientific (unreliable tests) & practical (incentives for infection), not fundamentally ethical, and must be weighed against ethical advantages of licenses. /7
Imagine, in 3 months, a survivor who is reliably shown to have short-term Covid-19 immunity. Should we subject her to restrictions that’d be justified for the general public, but mean she can’t see her grandmother in a nursing home, or her just-born grandchild in the hospital? /8
Preventing her from seeing loved ones is hard to justify ethically or legally, given the #leastrestrictivealternative principle. She & they are harmed twice over—first by Covid-19, and then by policies that are unjustified as applied to her. Immunity licenses can prevent this. /9
This is an important area of discussion, and I’m gratified to be published alongside Mark Hall & David Studdert https://jamanetwork.com/journals/jama/fullarticle/2765835, who emphasize that immunity licenses could benefit disadvantaged groups & that incentive problems needn’t be inexorable barriers./10
There is other important work in the last few days by @OFNorheim, who discusses empirical benefits of tailored, immunity-based policies https://www.nature.com/articles/s41591-020-0896-2, & by @alexandraphelan, who advocates vaccination certificates but rejects immunity licenses https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)31034-5/fulltext /11
Most worries Phelan & others like @FrancoiseBaylis
@nataliekofler raise—fraud, inequitable administration, racist policing, unchosen disadvantage—also apply to driver’s licenses & current pub health restrictions. They justify fair implementation, not categorical prohibition /12
@nataliekofler raise—fraud, inequitable administration, racist policing, unchosen disadvantage—also apply to driver’s licenses & current pub health restrictions. They justify fair implementation, not categorical prohibition /12
I’m troubled Baylis & Kofler say immunity licenses must be fought “tooth and nail”(!) & we should “never introduce” them https://www.cbc.ca/news/opinion/opinion-pandemic-coronavirus-immunity-passport-1.5551528 This rhetoric fails to take seriously the least restrictive alternative principle & ethical reasons to tailor restrictions to risk /13
Couple other thoughts based on JAMA comments: Immunity licenses don’t assume we will never have a vaccine—they could be based on vaccine-conferred immunity once there's a vaccine (see Phelan). And we acknowledge licenses may need periodic renewal, just like driver’s licenses./end
