Health and Healthcare Systems

COVID-19: The debate around vaccine passports

A syringe and a vial labelled "coronavirus disease (COVID-19) vaccine" are placed on a passport in this illustration taken April 27, 2021. REUTERS/Dado Ruvic/Illustration - RC2D4N9XPL5S

Vaccine hesitancy is not a new phenomenon. Image: REUTERS/Dado Ruvic/Illustration

Simon Kolstoe
Senior Lecturer in Evidence Based Healthcare and University Ethics Advisor, University of Portsmouth
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  • Vaccine passports and vaccine hesitancy is no new phenomenon.
  • Understanding the benefits associated with vaccines is important, writes an expert in evidence-based healthcare.
  • However, with COVID-19 a new issue of fairness, linked to global access to vaccines and respective passports has arisen.

At the age of 18 I very excitedly packed my bags and headed off for what turned into two years working on a charity hospital ship off the coast of West Africa. Prior to going I was given a list of vaccinations I needed, including yellow fever, hepatitis B, MMR and tetanus/diphtheria.

At the time I did not think twice about arranging (and paying) for these. It was simply the “vaccine passport” that was required for travelling to these parts of the world. Since I would also be working in a healthcare environment, I accepted the vaccines as needed to protect myself and the patients I would be caring for.

Twenty-five years later, a new vaccine is being added to the list of standard vaccinations – COVID-19. It is increasingly likely that we will all need to show evidence of our COVID-19 vaccination status in order to travel, access public events and perhaps even attend workplaces.

The experiences of the last year provide many reasons for using such a “vaccine passport” system, yet some people seem not to want one introduced. Why is it that this new vaccine might be viewed differently to the well-accepted, and somewhat routine, requirement for other vaccines?

Perhaps the first thing to acknowledge is that vaccine hesitancy is not a new phenomenon. Despite being one of the most effective ways of protecting people’s health, the act of injecting a foreign substance into the body understandably raises concerns.

For this reason, many vaccination programmes are voluntary, with health systems preferring to use persuasion rather than the law to get people to take them. In adults, mandatory vaccinations are usually only linked to specific professions (mainly in healthcare) and travel to certain parts of the world.

Given this history, a person keen to avoid all vaccines would simply choose not to follow certain professions or travel to certain places. This lack of vaccination would not impact other aspects of their life, including accessing public events or spaces and travelling to many popular holiday destinations.

But, with COVID-19, things will probably be different. It is likely that participating in these other activities will now also be subject to vaccination status – but is this fair?

The most common understanding of “fairness” is linked to opportunity. If different people have the same opportunities for something – which could be almost anything – the situation is often considered as fair. Relating this to COVID-19 vaccine passports, fairness could be seen as having equal opportunity for gaining a vaccine and thus a passport.

Within the UK, all adults over 18 have the opportunity to receive a vaccine. Where someone can’t – perhaps due to a medical reason – a “fair” vaccine passport system would need to take this into account. A fair system would also need to allow for any type of vaccine approved by the relevant regulator (the Medicines and Healthcare Products Regulatory Agency in the UK) to count for passport purposes.

Under this idea of fairness, the obvious area of concern would be visitors coming from other countries with limited opportunities to receive a vaccine. It could legitimately be considered “unfair” if such people were refused entry to the UK without some form of mitigating arrangement, such as making vaccination available on arrival in the UK followed by perhaps a mandatory period of quarantine.

But some may argue that fairness is about more than just equal opportunity. What about people who have moral or other objections to being vaccinated? Is it fair to also exclude them?

When considering this question, a thought experiment proposed by the American philosopher John Rawls can be helpful. The idea is to consider an issue such as vaccine passports, but try to forget anything that applies to your own personal position. From this “veil of ignorance”, you try to make a decision as to what would be a just or fair arrangement.

If access to COVID-19 vaccines is equitable, then requiring passports isn’t unfair.
Image: Rolex dela Peña

In the case of a moral objector to vaccination, this would require the individual to try to discount their own personal reasons for not being vaccinated, and instead think of what would be best for society as a whole.

Given the incredible harm caused by COVID-19 over the last year or so, increasing evidence for the tremendous success of vaccines in preventing deaths and mitigating the severest effects of the disease, the safety of vaccines, and the equal opportunity to receive a vaccine (certainly in the UK), it would be very hard to argue against the vaccine passport concept from a veil of ignorance position.

Of course the devil is almost always in the detail. A poorly implemented vaccine passport system could still be very unfair and cause tremendous unforeseen and undesirable circumstances. Currently there are a number of concerns relating to the recognition of different types, and even different batches, of COVID-19 vaccines. But overall it is important to distinguish between arguments about fair implementation, and arguments that concern the fairness of the concept as a whole.

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