COMMENTARY

Should We Soon Require Vaccine Passports?

Arthur L. Caplan, PhD

Disclosures

March 10, 2021

This transcript has been edited for clarity.

Hi. I'm Art Caplan. I'm at the Division of Medical Ethics at the New York University Grossman School of Medicine.

Well, what does the future hold with respect to vaccination? There have been endless debates going on about who should be eligible to get a vaccine. People have been pushing to the head of the line. We hear about some medical or concierge practices giving vaccines to ineligible people according to the criteria in their states.

Other people have offered donations to hospitals to get a vaccine, and people have lied about their age or their residency. It's basically pushing and shoving to the head of the line for some folks because vaccines are scarce.

That's not going to be true in a few months. Vaccines are going to be around and, if not in abundant supply, then there's going to be quite a bit more of them. Johnson & Johnson will have its vaccine out in big numbers. Pfizer and Moderna are planning to increase manufacturing, and other vaccines may show up from other companies and be available in the United States as well.

I think we're going to see a shift in the big ethics question. The debate now is, who gets the scarce resource? Who ought to be eligible? What do we do to condemn those who cheat or jump the line? The problem in a few months is going to be, what are we going to do about the non-vaccinators? What are we going to do about people who refuse? At that point, we're going to be trying to get to herd immunity. We're going to try to get our lives back to as normal as possible. We're going to need to have many people vaccinated, both to protect them and to make sure that, hopefully, transmission of the virus is reduced through vaccination. We don't have strong data on that, but it's looking like the vaccines will help reduce transmission as well.

We're going to have, at that point, many children who aren't vaccinated. People under 18, I think, make up 15% or 20% of the US population. That means there's a big chunk of folks who still could pass the virus around.

To get to herd immunity, we're going to need 60%-70% of the population to be vaccinated; 20% of our population includes kids under 18. They're not going to be vaccinated because we don't have data yet on the right dose, safety, and so on. They're probably not going to get vaccinated until the end of the year, if that.

We're already starting with a big problem that 20% of the population can still transmit the virus. Then we have vaccine refusal. When offered the current vaccines, 30% of the military have said no. In some groups, like nursing home staff, the rates that I've heard run as high as 40%-50% refusal for nurses and nursing aides. These problems have come up with other populations as well. They don't trust the vaccine, so we've got something to overcome.

The Future: Mandates and Vaccine Passports

Are we going to be able to get to herd immunity and get to restore our lives back to maximum normality? I think we're going to be talking about mandates and vaccine passports. Mandates just mean that you have to opt out of taking a vaccine; the presumption is that you're going to get it. There are strong mandates that say the only way to opt out is to come up with a health reason; everybody else has to do it. There are no religious exemptions, no philosophical exemptions, and no personal exemptions. You have to get vaccinated.

Weak mandates allow you to opt out and say, "I have a religious objection to vaccination or a personal objection; I just don't want to do it," or "I'll wear a mask" or "I'll stay home and work from home and try to accommodate (if you will) transmitting the virus by doing something other than vaccination."

I think we're going to see mandates, some strong ones, and I suspect the first place will be the military, followed pretty quickly by the healthcare workforce. We already have flu vaccine mandates. Some of you who watch me on these segments know that I've been a strong proponent for many years of flu vaccination for healthcare workers as mandatory, with very few opt-outs. COVID vaccination, I think, is going to get added to that list for doctors, nurses, and nursing aides in nursing homes and hospitals.

Then what I suspect is going to happen is that private industry is going to start to mandate, including cruise ships, airlines, hotels, restaurants, bars, and gyms. They're going to start to say, "Our staff has to be vaccinated to work here. It's safe. Come on in. Come on back." That'll be followed by, "If you want to come on this cruise, you're going to have to show me proof of vaccination. Otherwise, you can't travel."

The way these industries are going to function to restore trust is to mandate vaccination and to ask for proof of it, which we could call a vaccine passport. I think mandates and passports are in our future; it's the only way to overcome vaccine hesitancy and resistance. I think it's legal. I think it's ethical.

Interestingly enough, I wouldn't expect the government to be doing it. I think the private sector is going to do it. If you want your liberty and you want your freedom to travel, go out, use the gym, go to recreational activities, and go to sports, you're going to have to vaccinate and be able to prove it.

People might say, "I don't need to vaccinate; I've had COVID. I've been exposed and came out of it and there's no reason to vaccinate me. I must have antibodies." I don't think that argument is going to hold up as a reason not to get vaccinated either.

We don't know how long the resistance to COVID lasts naturally. Moreover, some people probably had mild exposures to the virus and built up just a little bit of antibody, while other people may have had repeated exposures and have more, and still other people may have had a single exposure to a very sick person. It's all over the place.

We can't trust natural immunity to give the kind of protection that vaccines do. Even though people may say, "I don't need it," unless they can really pass an antibody test that shows they've had long-lasting immune response to exposure, they're going to have to get vaccinated as well.

I'm Art Caplan at the Division of Medical Ethics at the New York University Grossman School of Medicine. Thanks for watching.

Arthur L. Caplan, PhD, is director of the Division of Medical Ethics at New York University Langone Medical Center and School of Medicine. He is the author or editor of 35 books and 750 peer-reviewed articles as well as a frequent commentator in the media on bioethical issues.

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