Vaccine passports are coming. But are they ethical?


Julian Savulescu, University of OxfordThe main way to control the pandemic, as we have all painfully found out, has been to restrict the movement of people. This stops people getting infected and infecting others. It is the justified basis for lockdowns, isolation, vaccine passports, and quarantining people who have been in high-risk areas.

It is the foundational ethical principle of any liberal society like Australia that the state should only restrict liberty if people represent a threat of harm to others, as John Stuart Mill famously articulated. This harm can take two forms.

Firstly, it can be direct harm to other people. Imagine you are about to board a plane. Authorities have reason to believe you are carrying a loaded gun. They are entitled to detain you. But they are obliged to investigate whether you actually have a gun and if you do not, they are obliged to free you and allow you to board your plane. To continue to detain you without just cause would be false imprisonment.

Having COVID is like carrying a loaded gun that can accidentally go off at any time. But if vaccines remove the bullets from the gun, the carriers are not a risk to other people and should be free.

In perfect conditions, vaccine passports are therefore a human rights issue under conditions of lockdown like Melbourne and Sydney are experiencing. Perfect conditions mean vaccines reduce transmission to other people sufficiently.

This means it is not discrimination to continue to restrict the liberty of the unvaccinated – it is just like quarantining those who have entered from high-risk countries overseas. Their liberty is restricted because they are a threat to others.

Discrimination occurs when people are treated differently on morally irrelevant grounds. But differential treatment on the basis of differential threat is morally relevant. That is why I can be quarantined if I have come into contact with a positive case: there is a relevant reason to treat me differently.

For example, some countries require travellers must be vaccinated against yellow fever and receive a card as a vaccine passport. No card, no travel. Infected travellers can bring yellow fever to the local mosquito population when they are bitten and thereby start an endemic infection.




Read more:
Vaccine passports are coming to Australia. How will they work and what will you need them for?


Do COVID vaccines fit into the same justification?

Hard to say. They appeared to reduce transmission of the original alpha variant by 50-60%, but it is unclear whether they significantly reduce transmission of delta, particularly over time. Israel’s data suggest those vaccinated in January could have as little as 16% protection against symptomatic disease by July (though still 80-90% protection against hospitalisation and severe disease). Other studies have shown similar viral loads in those infected with delta regardless of vaccination status.

To let the vaccinated roam free and restrict the freedom of movement of the unvaccinated would be discrimination if the vaccine does not significantly reduce transmission.

An important consideration in whether we publish the unvaccinated is clearer information about how much having the vaccine reduces transmission of the virus.
Daniel Pockett/AAP

Some have made colourful analogies: that requiring vaccination is like requiring a surgeon to scrub before an operation. Or an analogy I have used is that vaccination is like wearing a seatbelt – it is good for the wearer and for others in the car, as well as the health system.

But these analogies are flawed in two ways when it comes to COVID. First, vaccination does not reduce the chance of infecting others to the extent of surgical scrub techniques. Second, washing your hands or wearing a seatbelt benefits all concerned; vaccines have side effects, including lethal ones.

It’s true seatbelts can kill you, but overall they are expected to prevent more harm. Vaccination for COVID in low-risk groups such as children and young people is less clearly in their interests, though it is clearly in the interests of older people.

The inherent, unrecognised and unresolved problem in the vaccination and vaccine passport debate is one of proportionality. Vaccines may reduce transmission but do they reduce it enough to warrant mandates, including restricting freedoms of the unvaccinated? If vaccines were risk-free (like washing your hands), then mandating them would be reasonable – but the current vaccines do have rare risks that become more significant for groups at lower risk from COVID, such as children and young people.

Burden on the health system

There is a second way we can harm other people besides directly infecting them. We can use up a scarce resource like intensive care unit (ICU) beds by getting ill. In a public health system, we can indirectly harm others by taking more than our fair share of resources. Though Mill explicitly rejected “harm to self” as a justification for coercion, that was before a public health system with finite resources.

If vaccines significantly reduce the chance of becoming seriously ill in a pandemic, there can be a justification for using coercion to employ them to protect the health system in a public health emergency.

Again, proportionality is key: the strain on the health system must be severe. Otherwise any measure to promote health could be mandated, such as giving up smoking, losing weight, exercising, and so on. Freedom has some value and that includes the freedom to take on some risk.

How much risk we should tolerate and what level of coercion is justified depends on the safety and efficacy of the vaccines, the reduction in transmission, the gravity of the public health problem, the effectiveness of less liberty-restricting measures, the costs of coercion and, ultimately, the value of health and liberty.

Debates about vaccination and vaccine passports should also take into account the potential burden on the health system.
James Ross/AAP

Do COVID vaccines satisfy this criterion of reducing serious illness in a public health emergency? The evidence is very strong that they prevent serious illness with delta.

To introduce vaccine passports ethically requires either showing vaccines reduce transmission significantly or that, without them, we would face a health system crisis that is not reasonably sustainable.

Restricting people’s liberty, for example by vaccine passports, can be ethically justified in certain circumstances – but we need good evidence to justify them. Under conditions of lockdown, they can be a human rights issue.

Everything I have said about vaccine passports applies to natural immunity (immunity acquired by infection rather than vaccination), which provides ‘equal or higher protection’ against asymptomatic and symptomatic infection. (Of course, the whole point of the vaccine is to avoid or limit the harm of the first infection and it remains preferable as a strategy).




Read more:
Do vaccination passports take away freedoms? It depends on how you frame the question


What about only some people having to have vaccine passports?

Most people believe that restrictions of liberty, like vaccine passports, have to be universally applied or they are discriminatory. That’s wrong. Selective restriction of liberty can be justified for certain groups. This is what happens when we quarantine travellers because they are at increased risk of infecting others.

Selective restriction of liberty, including selective mandatory vaccination or passports, could be justified for “super spreaders” or those more likely to become ill (particularly the elderly but other also high-risk groups). On the latter approach, vaccine passports are more appropriate for older rather than younger people, as they are the ones most likely to benefit.

Consent

The problem in public health is that the person who makes the sacrifice is often not the one who benefits. By mandating a measure, the government is deciding to impose a burden on one group, sometimes to benefit a different group. The person who suffers the vaccine-related side effect (although very rare) may not have suffered adversely from COVID if they had got infected (even though there is a higher risk of this at the population level).

For this reason, consent is important. Because both being vaccinated and not being vaccinated involve risks, and we do not know on whom the risks will fall, it is preferable to consent to the particular risks for yourself, rather than have others impose them.

Not all groups in Australian society need to be treated the same on vaccine passports.
Bianca de Marchi/AAP

Responsibility

If people are choosing which risks they take, it is tempting to hold them accountable for the consequences of their choices. That would imply giving those who become ill after refusing vaccination lower priority if health resources are limited.

This requires that we can attribute responsibility to the individual, rather than their peer group, education, culture or other social factors. It requires that responsibility is treated equally across healthcare: we should not single out COVID-risky behaviour without treating other dangerous lifestyles, such as risky sex and unhealthy habits, in the same way. And it will limit the kinds of lives people can freely lead by making risky alternatives more difficult to pursue. Ultimately, it depends on what price we place on freedom and health.

Road fatalities would be reduced by drastically reducing speed limits. Yet we balance lives lost on the roads (and carbon emissions) with transport efficiency, pleasure and liberty. The same will eventually happen as we learn to live with COVID.

So where does this leave us?

Vaccine passports could be justified in Australia. But whether the burden of proof rests with the government to show the vaccines significantly reduce transmission (which they don’t appear to) or that the health system could not reasonably cope without them, or the burden rests on those who oppose vaccine passports depends on whether we value liberty more than health. Different countries will reasonably differ on this trade-off.

Vaccine passports could be also justified for certain groups of super spreaders or those more likely to become ill. This creates inequality, but we face a trade-off between equality versus maximising public health and liberty.

Ethics is about weighing different values. Decisions about vaccination should be fundamentally ethical, not political or purely medical.The Conversation

Julian Savulescu, Visiting Professor in Biomedical Ethics, Murdoch Children’s Research Institute; Distinguished Visiting Professor in Law, University of Melbourne; Uehiro Chair in Practical Ethics, University of Oxford

This article is republished from The Conversation under a Creative Commons license. Read the original article.

Vaccine passports are coming to Australia. How will they work and what will you need them for?


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Katie Attwell, The University of Western AustraliaEven before any COVID-19 vaccines were invented, vaccine passports for participation in public activities appeared likely.

Australia’s plagued vaccine rollout meant such requirements lay in a distant future — until now.

Australian political leaders have begun talking about a two-track future.

Proof of vaccination is already required in contexts around the globe by governments and private companies for people seeking to travel, dine and party.

We can expect a similar scenario here. So how will Australians be able to prove they’re fully vaccinated?

How can I prove I’m vaccinated?

NSW and Victoria are experiencing high new COVID case numbers. Both states have indicated reaching vaccination targets of 70-80% will be required for widespread easing of restrictions.

They’ve also suggested some freedoms will be only available to people who are fully vaccinated.

NSW Premier Gladys Berejiklian yesterday announced freedoms for fully vaccinated people once 70% of the state’s eligible population are double dosed. These include being able to go to hospitality venues, hairdressers and gyms, and have five people to your home.

Attention is now turning to the ways in which these and other Australian governments will require proof of vaccination for entry into public and private spaces.

Currently, vaccinated Australians can access a COVID-19 digital certificate through MyGov or the Express Plus Medicare app.

Those needing proof of vaccination for overseas travel will soon have this linked to their passport chips, along with a smartphone compatible QR code.

For returned travellers, this technology is likely to inform the circumstances under which they quarantine. Fully vaccinated travellers may have less stringent requirements than those who are unvaccinated, so technology to demonstrate this will be necessary.

States are also preparing to require proof of vaccination for local participation in hospitality venues and events. This would very likely be different to the way you would prove your vaccination status for travelling overseas.

New South Wales is set to trial and then introduce a vaccine passport in October.

Vaccination data from the Australian Immunisation Register would be embedded in the Service NSW app, meeting hospitality industry demands for a simple process.

Draft design of vaccine passport in Service NSW phone app
A draft of what a vaccine passport might look like in the Service NSW phone app.
Supplied, NSW Government

However, errors in the uploading and registration of data for vaccinated individuals will need resolving to avoid leaving them out in the cold.

Victorian Premier Daniel Andrews has announced the state will pursue its own version of a vaccine passport.

A “vaccinated economy” to be piloted in regional Victoria will allow only the double-dosed to access events, facilities and services. Again, the hospitality industry supports easy-to-use vaccine passports following their role in reopenings overseas.

What about people who can’t get vaccinated?

Currently, the only formal medical exemption in Australia for COVID-19 vaccines is available on a federal government form. Until now, this form has been used for the country’s “No Jab” policies.

Recently updated for COVID-19 vaccines, it lists a very narrow set of criteria for exemption and can be lodged only by specific medical practitioners.

All levels of government using vaccine passports will need to consider whether other types of exemptions are appropriate or necessary, including for people who have recently been infected with COVID and are advised not to vaccinate for up to six months.

Victoria’s human rights apparatus indicates a wider set of considerations or exemptions may be necessary for those unwilling or unable to vaccinate.

Governments will then need to work out how to manage these exemptions with the technologies they use.




Read more:
Could a France-style vaccine mandate for public spaces work in Australia? Legally, yes, but it’s complicated


One common way of managing people who are unvaccinated for any reason is to demand proof of a negative COVID-19 test.

Italy’s vaccination passport uses this alternative, and France’s Pass Sanitaire, or “health pass” has a similar option. Israel’s Green Pass system enables temporary passes for the uninfected, good for 72 hours.

Whether or how these negative tests would be integrated into Australian systems remains to be seen. Pending policies for nightclubs in England and Scotland are set to exclude the “negative test” opt out, meaning only the fully vaccinated will be able to access these venues.

Some Australian states and regions will be scrambling for technology if they want to go down the vaccine passport route.

The check-in app used in Queensland, Tasmania, the NT and the ACT lacks verification mechanisms and is not designed to hold a vaccine passport.

Western Australia is focused on vaccine requirements for interstate travellers and health-care workers, and so far has made no moves towards requiring vaccines for local activities; nor has South Australia.

Research suggests there’s public support for these kinds of measures in Australia, and there are good reasons to prefer governments introducing the terms of a vaccine mandate rather than private corporations.

However, there are issues of legality, viability and ethics to consider, with venue and individual compliance likely to remain a key issue.




Read more:
Would Australians support mandates for the COVID-19 vaccine? Our research suggests most would


The Conversation


Katie Attwell, Senior Lecturer, The University of Western Australia

This article is republished from The Conversation under a Creative Commons license. Read the original article.

Grattan on Friday: Vaccine passports are a better tool than mandating jabs for all jobs


Michelle Grattan, University of CanberraAs the nation proceeds – but still at an agonisingly slow pace – towards the targets of having 70% and 80% of those 16 and over fully vaccinated, the next big debate is about making the jab compulsory in workplaces.

This would give the community greater protection and accelerate the lifting of restrictions and opening the economy.

Dig deeper, however, and it’s a fraught issue, full of political, legal, practical and ethical complexities.

From the start, Scott Morrison has insisted his government would not make taking the vaccine mandatory.

It’s not just a matter of the anti-vaxxers, who are only a small, albeit noisy, minority.

It’s that many in the Coalition’s ranks and, even more important, among its base would be totally against compulsion. A fair number of these have already been angered by the extent of restrictions, believing civil rights have been excessively compromised.

So when individual businesses, notably the food processor SPC, started down the road of requiring workers to be vaccinated, Morrison last week had the solicitor-general brief national cabinet on the confusing legalities. He also said neither the federal government nor any state or territory intended to legislate to give employers the legal safety they would like.

“We are not going to seek to impose a mandatory vaccination program by the government by stealth,” he said this week.

A very hot potato has been left firmly in the hands of individual businesses.

They are in an awkward position. The advantage of having their workplaces vaccinated is obvious. But the legal position is unclear. In the absence of a public health order, they would be relying on directions to employees being judged lawful and reasonable. Inevitably there would be court challenges.

In advice published on Thursday, the Fair Work Ombudsman said: “In some cases, employers may be able to require their employees to be vaccinated against COVID-19. Employers should exercise caution if they’re considering making COVID-19 vaccinations mandatory in their workplace and get their own legal advice.”

ACTU secretary Sally McManus doubts the legality, short of public health orders, of employers forcing vaccinations and says support and encouragement for employees is the better way to go.

Even apart from any court challenge, some businesses would face division among their workers, and potential dismissals and voluntary departures. When Western Australia made vaccination compulsory for quarantine workers – surely a very reasonable requirement – it lost some of them.

Simon Longstaff, head of The Ethics Centre, points to the distinction between vaccination being compulsory or a condition for doing something.

Vaccination could be a condition for a person working in a company, just like donning safety equipment is for certain jobs, Longstaff says. “If they are not prepared to accept the condition, then they may choose not to work for an employer imposing such a condition.”

But “conditions” form a continuum. For example, having to be vaccinated to work in a hospital is very different to the jab being required to keep a job that involves minimal risk.

This takes us to the various ways of skinning the cat – and to vaccine “passports”. The government already has the beginnings of a vaccine passport scheme, although it won’t use that name – because its “base” doesn’t like the idea. It calls it a certificate.

The vaccine passport is the iron-fist-in-velvet-glove approach to imposing vaccinations.

Once we reach the 70% or 80%, and people are registered as being vaccinated, evidence of having had the jab will be the gateway to freedoms. Looked at the other way, lack of the passport would restrict what people could do.

A vaccine passport could be as necessary for international travel as a national passport. At a more mundane level, it could be required to eat at a restaurant just as, currently, people are told to sign in. Similarly, it could be needed to attend music or sporting events. Or to enter Parliament House.

Forcing people, directing or indirectly, to have a COVID vaccination involves sometimes competing rights – your right to choose whether to accept a vaccine, my right to be safe in the workplace and the community’s right to protection from a very serious and potentially fatal disease.

It is not as simple as “no jab no pay” for the vaccination of children, which only denies government benefits. In the COVID case we’re talking, in the extreme, about people’s access to jobs and livelihoods.

So where are we left?

When people are dealing with the vulnerable – most obviously in aged care – the rights of those being cared for clearly come ahead of the workers’ right to choose. National cabinet was correct in supporting the mandating of vaccinations of the aged care workforce.

Workers in quarantine, disability, and health care are, or should be, treated similarly by whoever employs them.

There are many other “frontline” workers, including those in supermarkets and hospitality. While this gets us back to the compulsion issue, it could be tackled, especially in occupations where there is high turnover, by giving preference in hiring to the vaccinated. This would be harsh, but less harsh than firing workers.

When everyone eligible has been offered the vaccine, we will have a better idea of the size of the minority of unvaccinated people we’re dealing with.

It’s important during the rollout to minimise this pool – to make sure as many as possible of the apathetic have been motivated and the hesitant persuaded.

The latest government “vaccine sentiment” survey, released on Thursday, had 79% of Australians intending to get vaccinated, or already done. According to rollout chief Lieutenant General J.J. Frewen, of the rest 14% were making up that their minds and only 7% were saying they won’t get vaccinated.

Incentives may be helpful, although they shouldn’t be as expensive or extensive as Anthony Albanese’s $300 for everyone vaccinated. Much better advertising is also needed, including niche campaigns where vaccination is below average.

The Australian community has proved remarkably compliant during COVID. Some hesitancy about AstraZeneca notwithstanding, we are lagging in our vaccination rate not primarily because of the public’s resistance or reluctance but because of the faults in the rollout. With improvements in that, and a combination of the positive and negative incentives of the vaccine passport, we can probably reach a vaccination level high enough to keep the community safe without having to go further down the road of compulsion.The Conversation

Michelle Grattan, Professorial Fellow, University of Canberra

This article is republished from The Conversation under a Creative Commons license. Read the original article.