31 Jul 2020
Guest post: This blog is an extended version of a presentation given by Professor Bobbie Farsides at last week’s Nuffield Council on Bioethics’ webinar “Ethical implications of antibody testing and 'immunity certification'."
A recording of the webinar is available here.
If all had gone to plan, on the day I took part in this webinar, I would have been in Malawi. No doubt today many of you should be in different places, and applying your time to different issues. So much has changed, yet at a crucially important level nothing has changed. A new virus has entered a world, the features of which are in many ways fixed, and this fixed reality cannot fail to affect the impact of this novel threat. However much we speak of a ‘new normal’ post-COVID, it is difficult to see the potential for transformation at a fundamental level.
I therefore want to argue that it is what has not changed in our society which makes the idea of immunity certification so worrying. When considering the ethical acceptability of such a proposal we have to do so in full and frank awareness of the facts about the context within which it would operate.
Back in early January few, if any, of us had heard of ‘coronavirus’. A virus which by July has resulted in over 540,000 deaths world-wide. Despite the best efforts of the worlds’ scientists, there is still much that we do not understand, and even the most optimistic predictions place a vaccination and/or effective new treatments somewhere in the less than immediate future. The complexity of the virology and immunology remains challenging even for the greatest scientific minds in the world, and the caution of the scientists when managing our expectations has been notable.
Across the world countries have gone into varying degrees of lockdown with unavoidable impacts on commerce, employment, education, mental health, etc. It is clearly a difficult political and practical challenge to manage communities out of a state which prioritised protection and disease prevention, and back into a world where every day activities carry a level of risk previously uncountenanced. As we now know, attempts to do so have sometimes had to be reversed at least at regional levels.
It is in the interests of managing this shift that the idea of immunity certification is often discussed. As such the clear focus is on giving those who have acquired immunity ways to re-enter the marketplace, the workplace, leisure facilities and other destinations of choice be that as employees, service providers, vendors, or consumers. Clearly all of this presupposes an effective testing system, trust and compliance.
Whilst we must acknowledge our scientific limitations in relation to understanding the virus and our ability to test for it, this feels like a moment in which to employ the philosopher’s prerogative to go beyond what is practicably possible at present in order to ask whether we should use immunity testing and certification as (to quote a recent commentator) ‘a get out of jail free card’. It is my belief that in our desire for preparedness we should focus on addressing the ‘whether’ rather than the ‘how’ to do this, although some of you may feel the two are inseparable.
As I said at the outset my response to this proposal rests on my thoughts about the world we live in, and specifically what remains the same in this world which seems so altered at first glance. Frankly, we still live in a world characterised by inequality between and within nations. We operate in a global political environment where supra national bodies such as the WHO have to transcend divisions and insurmountable differences based on power, wealth and ideology, and where major powers feel able to dissociate themselves from the collaborative approach exemplified by such institutions.
We live in a world which is finally waking up to and acknowledging grave injustices meted out over generations, meaning thousands of responsible people left the safety of their homes to protest that Black Lives Matter. This in a society where our recent history is blighted by the discriminatory practices embedded in stop and search strategies and where the statistics regarding who has been fined for breaking lockdown appear to reflect the targeting of particular communities and ethnic groups.
The disproportionate loss of life within BAME communities in the UK means that this pandemic has shone a light on existing social and health inequalities and our inability to understand or correct them. Yet it is against this background that we would be introducing a new and potentially stigmatising division into our society. We really need to know whether members of communities made more vulnerable by the virus believe that an immunity certification system will be designed to serve their interests, and operated in ways that protect their rights. We need to work with the people of Birmingham, Leicester, Bradford and Brent before we assume anything or do anything.
In testing the ethical feasibility of any proposal it is wise to ask how it will impact upon the most vulnerable in our society. Some of the most heart rending stories of the lockdown period came from homeless people who were given temporary housing to remove them from the streets. For a brief time some of them saw how life could be different and regained an identity denied to them by their homeless state. How if at all would these people be served by a certification programme when their basic rights and claims to societal resources are already so compromised? What about the refugee or the asylum seeker, will they be able to make themselves sufficiently visible to be part of whatever this scheme has to offer? What about the disabled person whose assiduous adherence to shielding has protected them from the virus, but now discounts them from a certificate which is the key to doors they might already find difficult to open? It is hard to envisage a situation in which a certificate becomes a corrective for the existing disadvantages experienced by these groups, and all too easy to imagine how they might come to lose out even more.
There are of course those of us who have continued to enjoy our privilege throughout the lockdown period. Have we got good reason to feel that the system will work for us, if, that is, we can put aside our concern for others? Again I urge you to consider the context within which this proposal would be taken forward, and ask whether it provides a sound basis from which to proceed.
We have watched how the political response has unfolded and despite the Government’s mantra of ‘following the science’ we have learnt that facts and interpretations of facts are disputed, statistics are carefully managed, political advisers are present in scientific meetings, and political decisions have not always followed the science. We have also observed that the rules famously do not appear to apply equally to all. Night after night we watched as highly respected scientific and medical figures became the adjuncts of ministers in carefully managed daily briefings, only to disappear if they went off script. We have observed decisions which clearly supported the agenda of out-sourcing, privatisation, and fragmentation of the NHS whilst failing to best serve patients or carers. We have seen our Government pick and choose who to work with in this space, circumventing normal processes to support parties ill equipped to deliver what was required ignoring or excluding others who had much to offer. We have seen a form of scientific and technological nationalism and a recurrent wish to be ‘first and best’ divert attention from more established ways of doing things. We have noted an increasingly urgent emphasis upon opening up and protecting the economy, and have seen how this has come to compete directly with the philosophy of lockdown which rested upon a sense of solidarity and a shared commitment to protecting the NHS and ‘beating the virus’. We realise our Prime Minister is reluctant to take responsibility for the actions of his government and its advisers, whilst being quick to assign responsibility and blame to others. It is against this background that we must ask whether the immunity passport is the correct means to an end we feel it safe for our government to prioritise and pursue?
So before we start debating the many difficult and complex issues relating to how to introduce and operate a testing and certification we need to pause and consider where it would land. Only if we feel safe in this regard should we start to address the finer points of immunology, the feasibility of different testing regimes, the issues around false positives and false negatives, questions of who will issue your certificate and where it will and will not be permitted to count, the merits and demerits of deliberate infection in the interests of acquiring immunity, whether the system will be supported by legislation, and if and how and by whom digressions will be detected and punished, the problem of counterfeit documents and fraudulent test results, the question of who pays for what , who runs the system etc. etc. etc.
We the privileged need to recognise how the structural characteristics of our society and the political priorities of our government will dictate in large part how such a proposal could play out in reality. We need to understand that the dominant structure upon which to focus in this instance is the market, which famously and unashamedly benefits the few, often at the cost of the many. Immunity certification is primarily a ticket back into the market place – a means to exercising your negative liberty. It is not a welfare document, once you have one you will be able to enter a market which will adjust to accommodating this feature of your identity. If you cannot acquire one, be that through care and self-sacrifice in avoiding infection or pure luck it is hard to see how the market will adjust to protect you or promote your interests, and it is unclear how the government would compensate for this. We who enjoy privilege must appreciate that we too would be subject to the impact of a system which categorised people in terms of their relationship to a virus and treated them accordingly. The potential for precarity in our lives is increasingly apparent, and we are told that the economic realities of the coming years will be harsh. We should not therefore be complacent about the fact that those with whom you compete or collaborate may or may not be ‘certificate holders’ and this could play out in a variety of ways which prove that it is far from the golden ticket its advocates might claim.
So, whether it is from a position of moral concern for others or of self-interest, this is an issue on which we really do need to remain alert. At the same time, we must not allow ourselves to be distracted from more important and potentially valuable activities which have a greater chance of protecting us from the virus now and in the future. And we must hope that we can find ways forward which build upon feelings of solidarity, common purpose and collaboration rather than engaging the virus to extend and amplify the sense of ‘us’ and ‘them’ which already exists to such a regrettable extent in our society.