Most of the world is eyeing the next stage of the pandemic — which means restarting as much of the economy as possible without risking a rising new tide of infections.

In this scenario, one possible approach would be to give people who have had the disease and defeated it a certificate of immunity, allowing said people to operate normally as they would presumably be immune to the disease.

This idea, which has already been discussed in Germany and the UK among other countries, would open up a major can of worms and needs to be analyzed extremely carefully if we ever want to implement it.

An unparalleled idea

Medical certifications are not exactly a new idea. Certifications are common parts of infection control strategies, especially for indicating childhood vaccination. Also, many countries require visitors to show a yellow fever vaccination certificate. But this is a different matter altogether.

For starters, COVID-19 is not a vaccine-preventable disease (at least not yet). This means that any inoculation must be due to a prior infection — an absolute novelty in medical certification. Secondly, this would likely only apply to selected activities (such as factory or construction workers, teachers, or public transit operators), and thirdly, a lot of civil liberties could depend on this. For instance, the freedom of association, worship, work, and travel might be temporarily disallowed for most citizens but allowed for those with an immunity passport.

This treads into some delicate legal issues, not to mention very complex ethical issues.

But before we get into those, let’s first look at the feasibility aspect.

Is immunity even guaranteed?

Our understanding of SARS-CoV-2 is, unfortunately, still rudimentary. We still don’t know how much immunity the infection confers, whether everyone gets this immunity or not, how long this immunity would last, and what type of antibodies indicate this immunity.

Antibody tests have proliferated in the past few weeks, but we still don’t have a fully-proven antibody test that works for everyone. There are many unknowns about the way immunity is generated against COVID-19 and how tests could detect the antibodies responsible for this immunity.

Immunity-based licenses can only be introduced if serology testing is accurate so we’re not even sure if immunity passports are a realistic possibility. Ideally, we’d have a much clearer understanding of these issues, and then deliberate the social and ethical implications of this approach.

The ethics of immunity passports

In a viewpoint published in the medical journal JAMA, two researchers argue that immunity licenses should not be evaluated against a baseline of normalcy (ie uninfected free movement), but rather against the alternative of enforcing strict public health restriction for many months. From an ethical perspective, this is extremely important because the discussion becomes not about whether these immunity passports risk exacerbating inequality — but rather if this accentuated inequality is better than the one produced by a stricter quarantine.

“The ethics of COVID-19 immunity licenses can be assessed with respect to 3 fundamental ethical values: the maximization of benefit; priority to the least advantaged; and treating people equally. These values can be consistent with a well-designed implementation of immunity licenses,” write Govind Persad and Ezekiel J. Emanuel in JAMA.

The first point is fairly straightforward. Why would you issue these certificates in the first place? Because you have a group of people who are allowed to work, travel, worship, etc, without risking an increase in the number of cases. This helps this economy and improves the quality of life of people who have demonstrably recovered from COVID-19. But inequitable access to testing is likely to plague vulnerable communities.

People in poorer communities may be less likely to get tested in the first place, in which case they will be less likely to get an immunity passport, which will perpetuate a state of poverty.

In a separate JAMA Viewpoint, two other researchers, Mark A. Hall and David M. Studdert write that certifying those who are immune may discriminate against those who aren’t.

“Even when differentiating is legal, it can still be unfair. Certifying those who are fit may stigmatize those who are not. There is ample historical evidence that tying advantage to fitness can amplify existing socioeconomic disparities. At the extreme, critics warn that excessive immunity advantages could create an Orwellian or dystopian social apartheid. Those are serious concerns, but the picture is more nuanced.”

While immunity licensing can be ethical in principle, it could also lead to the stigmatization of people. They could split communities in two, and stigmatize those without immunity — much like the yellow stars Nazis forced Jews to wear. Those “yellow stars” (and more importantly, the attitudes surroudning them) showed just how easy classification can lead to discrimination.

Nevertheless, Persad and Emanuel argue that immunity-based licenses do not violate equal treatment because the factors used to grant a license are not discriminatory, like race or religion, but instead grounded in relevant evidence.

Perverse incentives

Furthermore, if we are creating an incentive for people to become immune, aren’t we creating an incentive for people to become sick? If you’re healthy and/or reckless, you may think you can defeat the disease easily and therefore may feel incentivized to get the disease in order to get an immune certificate. The behavior is reminiscent of the “pox parties” that some vaccine-opposed parents hold for their children — but COVID-19 is far more dangerous and unpredictable than the pox.

Then, as you are creating an incentive for some people to get sick, you are also creating a disincentive for people to follow strict social distancing rules. People who are conscientious and follow the best medical advice and don’t get sick will feel disadvantaged by the system, and rightfully so.

Ultimately, this balance of perverse incentives will need to be carefully balanced to ensure that immunity certifications don’t cause more problems than they solve.

Practical problems

Even if an idea is good, it doesn’t necessarily mean it will be applied in a good way — and this is very much the case here. The benefits of immunity licenses could encourage forgery, illegal markets, or fraud by unethical physicians or testing facilities. This could lead to a stealthy increase in the number of infections, which is absolutely what we don’t want to have happen.

These problems underscore the need for careful implementation through strategies like anti-counterfeiting designs, cryptographic or biometric features, and reliable chains of verification for tests.

Ultimately, the implementation strategy of this will be extremely important, and careful consideration needs to be given to every potential shortcoming of the approach — an immunity certification is not something that should be granted with ease.

The bottom line

It’s extremely important then to address inequalities and stigmatization that immunity passports could produce, but it’s also important to consider that refusing immunity licensing can also lead to the discriminatory treatment. Without an official immunity licensing system, researchers argue, many businesses and individuals might opt for an unregulated system, with lower accuracy and higher potential for economic and social fallout.

In many ways, we are going through an unprecedented period, and we may have to deploy unprecedented solutions to keep society going in the year(s) until a vaccine is developed.

This is an opportunity to address and reduce inequalities, not to introduce another discrimination formula, the researchers conclude.