The COVID-19 crisis triggered sweeping restrictions on civil liberties across society. Lockdowns have started to ease, but in response to concerns about a second wave of infections and coping with the virus in the medium-term, governments and private companies are exploring the idea of ‘immunity certification’ and wider public health identity systems for managing COVID-19 risks.
Governments and private actors will need to demonstrate the benefit to public health, and how it will mitigate any risks, in order to justify deployment and have a legitimate basis to roll out a public health identity system. This raises a series of ethical, legal and social questions which we’ll be exploring with panellists:
- Is the creation of a public health identity justifiable to protect the health of others?
- Will such a system perpetuate existing inequalities, biases and discrimination?
- Could perverse incentives to get infected mean systems cause more harm than good to public health? How might those incentives be offset by social policies?
- Are the existing legal governance mechanisms for these systems sufficient? What additional regulations or legislation might be required to minimise harms from these systems if they are created?
This is the second in a new series of work at the Ada Lovelace Institute which is exploring the developments of public health identity systems. By that, we are really talking about some form of verification, which brings together private health data with a public health identity, which can be used to stream society or enable people to access certain services or certain spaces based on their risk profile.
We have seen this emerging in many different forms around the world in response to COVID-19. Since our last event a few weeks ago, we have launched an international monitor to keep track of both the deployment of the systems by countries but also companies and whether or not there are laws surrounding them and what practice looks like around these systems.
At present, I think I’m right in saying the latest WHO line on this has been very clear: there isn’t enough evidence about the efficacy of an antibody mediated immunity to be able to guarantee accuracy of an immunity passport. They cautioned that bringing out something like an immunity passport might increase risk of continued transmission in communities. The evidence on this is moving rapidly, even if that is the WHO position today, that might change and evolve.
At our last event, Professor Danny Awkman laid out a myriad of reasons why a positive antibody test is not a guarantee of immunity but this won’t stop some countries going ahead. I suspect that immunity systems won’t be the only form that we see of this.
As well as thinking about those, we should also consider how an early idea around an immunity passport might evolve into applications that move away from a more binary positive or negative score to something approximating or engaging more with an individualised risk or based on health factors.
I think it’s fair to say that in many countries, and certainly in the UK, the notion of restricting freedoms based on health status would have been unthinkable up until a few months ago. It’s only in the face of this huge social threat that it is right that these are contemplated but the answer to whether or not they can be justified can’t just be owned by a single app developer. This is something that, as a society, we need to work through collectively and to really grapple with this we need to draw on a whole range of challenging questions. They include whether immunity means anything, how this might play outside alongside a public health strategy, how it might affect the behaviour of citizens – whether it might cause problems or perverse incentives – as well as how it might affect certain sections of society differently.
So when considering any form of digital identity, we need to think about the social, political, ethical and legal issues.
What are some of the ethical questions we should be considering?
Immunity passports, health status apps, or even tracking bracelets for home isolation, rather than hotel isolation, quarantine of those visiting high-risk areas or who have symptoms, or the selective lockdown of the elderly.
All these policies are about the selective management of risk.
And in all of these different policies, there are four key questions you have to answer:
- Does the intervention do more good overall than the alternative?
- Is it the least liberty restricting version of that policy?
- Does it unjustly discriminate against any group?
- Are there any public interest considerations?
How do immunity passports answer the first three of these questions, in comparison to a complete lockdown? Would we be right to move from a complete lockdown to one which enabled greater freedoms to people who had higher levels of immunity?
The basic argument in favour of an immunity passport is based on a fundamental principle of liberal societies – that the only ground for restricting people’s liberty is when they represent harm to other people. There’s no reason to restrict you if you are no threat to other people.
In this case, the harm is either infecting somebody else or even getting sick yourself and using a limited resource like a ventilator, which there is competition for where there are shortages. Those that are at a higher risk of passing on infection or using limited resources if they become ill can be quarantined or isolated and they lose their freedom. At the start of the pandemic, the UK did quarantine people if they had been to a high-risk area because they were at a high risk of infecting other people or getting sick themselves.
So, the first argument against immunity passports is that we are uncertain as to whether antibodies confer immunity and actually lower your risk. Experiences from other relevant coronaviruses such as SARS say yes, at least for two to three years. It may be time-limited and that does reduce the amount of good but it doesn’t negate the good entirely. The argument that we can’t tell whether antibodies will produce immunity is overblown.
The second argument against their use is that the tests that we have are inaccurate. The tests will lead to false positives, saying somebody has antibodies when they don’t, or false negatives, saying they don’t have antibodies when they do.
But no test is perfect, we just have to make sure it’s reliable enough to do more good than the alternative and the alternative is a lockdown. So, how bad is the sort of reliability of these tests? Public Health England has now approved a test by Roche which has a 99.8% specificity and 100% sensitivity. If used in London with a population of about nine million people and a background prevalence of antibodies of 18%, the rate of false positives would be low, only about 14,760 people. That would mean you could release 1.62 million people with 14,760 people thinking they have antibodies but they don’t. That is not to say they will necessarily contract COVID-19, but even if they all contracted COVID-19, only about 1 to 14 of them would die if they’re under the age of 65. So, you are releasing 1.62 million people in London for the chance of at most under 20 people dying.
Where the baseline immunity is higher, the tests have a higher positive predictive value. For example, in healthcare workers, they’re likely to be highly useful. It’s also the case that where people are less vulnerable to the effects, a false positive result is less important. For example in younger people.
There are also secondary benefits of allowing greater mobilisation of people with antibodies. First of all, there’s concern that people haven’t been seeking medical care for non-COVID-19 related illnesses for fearing of contracting the virus. With a positive antibody test, they would be more likely to seek healthcare. For those caring for the vulnerable or elderly populations, there would be greater safety in being able to carry out those roles, in addition to allowing people to return to work, pay taxes and support the economy.
Some people have talked about the negative secondary effects, for example, undermining social cohesion. However, this is speculative. There are also questions about the reliability of enforcement but this applies to any kind of passport, including the regular passport, a driving licence or age identification.
Some people have objected claiming they will cause perverse incentives, for example, they would reward reckless behaviour. There may even be the incentive to intentionally infect oneself. One survey said the number of people that would seek to deliberately infect themselves is low, the vast majority would not consider intentional infection. But the way to combat these perverse incentives is to reward good behaviour, supporting lockdown through furlough and tax breaks, access to home and food deliveries, reducing disadvantage perhaps requiring those with antibodies to perform community service to those that are not immune and punishing bad behaviour through fines or stigmatisation.
There are concerns that there would be coercion to undergo testing by employers. But again, we have to compare this to the status quo. Many businesses are already going bust and people are losing their jobs and we can implement workplace protections and create flexible working arrangements for those who are antibody negative.
One of the strongest objections is it would be unfair to discriminate against people according to whether they have antibodies or not. But antibodies test two relevant properties, one is the possibility or probability to infecting other people, and quarantine and isolation were both founded on isolating those who have a higher probability of infecting others. The second relevant property is they predict the probability of falling ill and utilising limited healthcare resources. But again, this is a relevant property and selective isolation of the elderly and those with co-morbidities can be justified on this basis.
Selective discrimination on the basis of risk is only unjust discrimination if the property that elevates one’s risk is as a result of one’s past injustice. The presence of antibodies is not the result of some past injustice. Just as being more vulnerable or having less long to live if you’re elderly is not the result of some injustice.
Will they exacerbate inequality? Provided they’re available free or at low cost to all members of the community, they won’t exacerbate existing socioeconomic inequalities. Not allowing some people to enjoy more freedom and wellbeing because not everyone can enjoy it is an example of levelling down inequality. We shouldn’t level down people.
We should implement policies which promote wellbeing and liberty and allow those who have been enjoying those to enjoy them, particularly when there are secondary benefits. I think immunity passports are one example where it can help.
Will any immunity certification system perpetuate existing inequalities and discrimination? Or can we design a system in which these risks are mitigated or even not present?
There are a number of technical and practical challenges with the proposals. We have a lot of assumptions about how immunity will work. We don’t really know what kind of protection it might provide in terms of re-infection. We don’t really know for how long. All of us need to show a whole lot more humility to what we do or don’t know about this virus.
A lot of the points about immunity passports right now would be different if we had a vaccine, where we have greater knowledge and not just suppositions. Based on what we know right now, the various proposals we have seen for digital apps or paper documentation, are ultimately starting to build a platform for restricting human rights.
There are ways in which people see this as improving liberty and freedom but we’re actually moving in the opposite direction. They do also ultimately represent a threat to public health. But most importantly, you are really at risk of increasing discrimination. There are very real concerns that these will entrench existing systemic racism.
There are a couple of ways in which the immunity passports are going to hurt everyone and then there are more specific ways in which I think it will hurt subpopulations.
I think it will hurt everyone in that it will be a system for ultimately monitoring people and thereby eroding privacy. There’s already conversation that after you have invested all this time, money and talent to develop these digital apps, there will be all kinds of incentives to broaden their use. So it won’t just be for COVID-19, it might be for any other kind of infectious disease, then it will be for your whole health record, then it might be that you have done genetic testing, why not add your health insurance or life insurance policies?
At some point, we need to think about how much privacy we want to trade-off. Is it fair? Is it in fact accurate that we have to trade-off privacy to get at health? I don’t think we do. One of the reasons I don’t think we do is because I don’t think that we should be comparing this to the lockdown as the alternative.
There are other alternatives and they are the ones we have been living with. We have been coming out of lockdown and relying on a range of huge public health measures and we know they work. As we learn more, there are in fact public health measures that we could put in place. There are alternatives to lockdown. I don’t think we only need to be thinking about immunity passports.
One of the things we have already seen in terms of access to viral testing is that different communities have had privileged access. We know this with viral testing, why would we not assume the same thing with happen with immunity testing? We have good evidence to say it will carry over. Beyond that, one of the things we need to think about is existing systemic racism, existing social stratification and how this will be exacerbated. I think we will see this play out in three places: in the workplace, on the streets and at the borders.
These are things that all of us want in terms of freedom of movement and right now, I think we should be thinking about the ways in which we can guarantee that freedom of movement to everybody, rather than thinking we should guarantee it to small minorities without paying attention to who those minorities might be.
I think we do need to think about past injustices and think about who is it that’s working in the high-risk jobs, the low-paid, front-facing jobs. These are typically people of colour and they are the people that have already been at increased risk of infection. They have had to go out to work, whereas some people have been able to work safely in my home because I have a computer-facing job. Who are the people, likely to be exposed in that context, likely to get sick?
When I’ve made that point, people turn it around, they are the first people to benefit from an immunity passport, because they’re the people who have gone out into the world and gotten sick. But think about what you’re doing there, you can exploit people, to what end? Because you want to send them back into the world to do those jobs that you perhaps don’t want to do.
We need to think carefully about the assumptions built into that. We are assuming these individuals in these low-page minimum wage jobs can’t afford to do this immunity testing. You may turn around and say the employer will do the immunity testing. But isn’t that the perfect way to lock your community into the low-paid jobs? You are dependent on them being willing to pay for that cost upfront.
If we think about it on the streets, in my small part of the world, we have a process called carding where people can be stopped on the street and asked for personal information and the police can make certain decisions about the freedom of movement for that person. In the UK, you have stop and search. In that context, you have now given the authorities one more reason to stop innocent people on the street and to demand some kind of proof of identity. Now, with specific health data attached to that.
I’m worried about the ways in which that can be abused because we have data that those policies disproportionately affect people of colour. If it already does that now, why wouldn’t we think about that in this context? We have already seen this with COVID-19. We have data that shows that people who have been violating lockdowns or stay at home orders when those have been in place have been disproportionately people of colour. I’m talking about the data that we already have about systemic racism and the ways in which this will be exacerbated.
My last point is about borders. We are seeing a number of initiatives by private corporations to introduce some version of immunity testing or immunity passports. Again, there are issues of cost which I think are significant to who will be benefiting from that. Who are the people who are able to go back out and travel? It is in the context of travel and it is certain kinds of workers. We need to pay attention to that. I will say there are supposed to be laws in those places that will prohibit racial profiling at borders and yet we know what happens.
I’m worried about one more way in which we will now use not things like geography, which country have you come from, or have you been to in the last period of time, but we’ll be using biology as the basis on which to discriminate and we will be doing it with something that is supposed to be objective like an immunity passport, failing to understanding that it’s building on a system that is socially unjust.
I’m saying in terms of the concerns I have, and the concerns that I think most people have, we need to be realistic and we need to think about ways in which we can get everybody back out into the workplace and to focus narrowly on a subset of people that will be able to show they’ve had exposure, hopefully recover, and that we hope have some kind of immunity is in fact not to look at reality.
I want to make two points with respect to that. I don’t think we have paid attention to the complexity in terms of just the numbers. We are eight billion people nearly on this planet. It as global problem. How we can get all of those people immunity tests made? We will need eight billion, no, we need a minimum of 16 billion and we’re in fact going to need more than that because if I don’t test positive today, maybe I want to come back in two weeks and try again or in a month and try again so we don’t need the volume of tests we need. Places are planning to make a lot of tests. I think Roche predicts a million a month. Do you know how long it will take to get up to 16 billion? There are real practical issues there.
The last important practical issue if you introduce this and put the emphasis on things that most people care about and that really do seem important, let’s take healthcare providers. Right now we don’t have 100% of our healthcare providers with a status that would allow them to pass an immunity test. Let’s say it’s really high and really high might be 30%, what do you want to do with the other 70% of your healthcare providers, do you send them home? You don’t pass a test and we don’t want you here.
You want your whole population out there at 100% capacity because what you really want do is restart your economy and you need all of those consumers out there in the world. You don’t just need 10% of the world out there able to have a coffee, sit in a restaurant, go to a museum, go by a dress. You need everybody out there. I want us to think creatively about ways to get the whole population out there not just some small privileged subset.
How do these ethical questions translate into existing law and what laws might we need if these systems are rolled out by governments or private actors?
I’m going to begin by touching on the fact that they relate to two of the key recommendations that came from a report published by the Ada Lovelace Institute called No Green Lights, No Red Lines. Public health monitoring in general, and public health identification, is high stakes and high risk and they need to be justified as appropriate and necessary to be adopted.
I’m going to look at that from a human rights law perspective particularly in terms of the context of the UK. Any tools like this, because these are technological tools, are not the only ones we can possibly rely on and there are other responses to deal with the pandemic. We currently know that social distancing is proving to be an effective one. If we implement a tool, we need to take steps to ensure we are safeguarding against errors, harps and any discrimination. As the Ada Lovelace Institute report noted, these harms are not just privacy, data security, they also are very far reaching in terms of non-discrimination.
Any of these public health monitoring identity systems like this type of certification using antibodies need to be lawfully or legally compliant and there are three main pieces of legislation and provisions here:
- The right to privacy and non-discrimination under the European Convention of human rights, articles 8 and 14.
- The UK Human Rights Act
- The UK Data Protection Act 2018
Then it must meet three criteria:
- It must meet the tests of legality
- It must have a legitimate aim that sets out exactly what the system is intended for
- It must not have disproportionate impact on our rights in democratic society.
First of all, if it would have to meet the tests of legality and this is a clear well-established rule of law requirement that you have a clear legal basis that would set out how and when authorities have the power to use a certificated system like this. International human rights best practice in this a binding statutory framework, an act or it is at least a legally binding code of practice.
Secondly, you should have a legitimate aim for what this system is exactly intended for, so you are designing it appropriately in terms of safeguards and scope and powers. In this case, the legitimate aim is quite straightforward. As we understand it, it is for the protection of public health and safety. We need to understand what the exact contours of that are and who gets involved in terms of access and sharing of that data.
Finally, we have what is necessary in a democratic society and what is appropriate in terms of impacts this will happen on our rights, not just advancing the economy and making sure that we’re all safe to go back into public spaces. Given that we have such a high risk to so many rights not just privacy but also non-discrimination, it means that we also have a higher threshold of safeguards because you have huge impacts of people’s private lives but also their freedom of movement to travel and to work.
The test for policymakers in terms of proportionality is a measure like this, this antibodies test, is there such a pressing social need that we would introduce legislation that would permit the introduction of these certificates?
In the UK, and across the EU, we have a requirement under data protection law that before any measure like this could be developed, you would have to undertake a data protection impact assessment. There are some key questions that policymakers should have addressed before a mess like this got implemented:
- What legal basis is there for adopting such a far-reaching health monitoring message and what safeguards does it provide for?
- If we do have these safeguards, how exactly are they countering and reducing all of the possible harms?
- What types of personal data is this antibodies test system collecting? We’re not just talking about a person’s health data status, we are also talking about the verification system, so does that include for example facial recognition?
- What authorities are going to be given the power to collect this kind of data to be able to have the power to request this type of certification? Is law enforcement going to be involved?
- Who will this data be shared with, for what purpose?
- Whose oversight body will be monitoring and reviewing that all of this is actually effective and it’s working in tandem with all of other COVID-19 responses that the Governments have implemented? What is the knock-on effect?
- Finally, on what grounds can we show that these antibodies certificates are necessary and proportionate in a democratic society?
The European Data Protection Board, a collection of all of the data protection supervisory authorities in the EU, recently stated that because we’ve got such a high risk to human rights posed by such a measure like this, that you have to take into account the scientific evidence when you’re putting forward that this a necessary and proportionate measure.
Right now, based on the available scientific evidence right now, we don’t know what levels of antibodies are needed to protect from a second infection or how long that protection might last. We really don’t know how useful these certificates are and how often we should renew them and who is going to authenticate them.
In Spain, research has shown that only 5% of the population has been exposed to the virus. If we implemented this measure right now it would only be relevant to a small proportion of our population. It does seem in terms of resources and more immediate short-term responses that there are other responses we should be focusing our time and precious resources on given the urgency of having to deal with the pandemic.
There are so many unanswered questions about how long immunity will last based on current available scientific evidence, that this seems like more of a medium-term measure and certainly not for the short-term. When we have a vaccine and we see that has objective scientific evidence of effectiveness, this is when we should have conversations about certification because immunity doesn’t even come into it until we get to that stage.
For the moment, we have no scientific evidence that satisfies this key proportionality test that antibody certificates meet a pressing social need. Making them mandatory runs huge risks of making the most vulnerable people in society under pressure to obtain an antibody certificate, so you could get caught in this trap where employers are being relied upon to pay for them but at the same time, you could have employees that will deliberately infect themselves because there’s no other avenue for them if they are going to work and feed their families and support themselves. In terms of the more vulnerable groups in society, there are greater risks for them because it’s been shown they are more at risk from symptoms of the virus. We really need to be taking all these factors into account.
We have no clear legal basis for adopting an anti-certification system in the UK right now. The Joint Committee of Human Rights put forward a specific piece of draft legislation, so we would have specific safeguards and a specific oversight system to oversee the UK contact tracing initiatives. Unfortunately, this particular Bill was rejected by the Home Secretary on the basis that we have existing legislation under the Human Rights Act and the Data Protection Act that provide the necessary protection texts and oversight.
But this is highly questionable given that our current law only provides a really general framework of protections and what it does then is place the burden of how to apply safeguards and protections for antibodies certificates on the public and other bodies, like employers for instance, who have wade through a very complex patchwork of existing legislation and many judgements on top of that.
It’s very difficult to understand how this really complex patchwork of laws that we have can be considered to be a clear set of understandable rules and safeguards that are publicly accessible to individuals so that they know who can use and request these certificates from them and know what redress is available to them.
Even if we had these lists of requirements met, the proportionality and the data minute minimisation principle that we are only collecting this data, potential biometric data in terms of verifying authenticity, is actually strictly necessary.
There do seem to be other alternatives that achieving the same legitimate purpose of protecting public health. We’ll have to closely follow scientific evidence to see how this develops over the next few years.
I would strongly argue that the case for the legality and proportionality of antibody certificates currently falls very short, raises considerable concerns, and can be summed up in three words: Unproven, unnecessary, and unjustified.
What is it the governments should be doing? What processes should be put in place to resolve these problems? Can social policies offset the social harms you have raised?
We need more research. We also need to look at all the strategies such as aggressive contact tracing, contact apps, etc. At the moment, the UK has moved from a complete lockdown to a partial lockdown, so if we get a second wave, and there’s the move to a higher level of lockdown again, for example, as has occurred in Melbourne, Australia, then I think you have to ask is an antibody passport a contribution to dealing with the problem?
It’s obviously not the whole solution but will it do more harm than good? I think that when you talk about whether it is proportionate, you have to compare it to the proportionality of a complete lockdown. At the moment, I think the Government wouldn’t be justified in further restricting liberty of people who are immune negative. In the context of a complete lockdown, are antibody passports enough to enable certain freedoms and certain socially beneficial roles to occur? The Government should be getting more evidence and tailoring policy to the circumstances.
This issue of mandatory antibody passports or immunity passports means only one option. You can also explore voluntary passports for people who want to know and want to be able to go back to work because, otherwise, they’re going to lose their job. People of colour working in the lowest paid jobs and having the highest level of antibodies and being forced back to work, it may be that these people want to go back to work if they know with a level of certainty that they’re at a lower risk. You’ve got to have a policy that is relevant to the circumstances of the time and the evidence of the time.
When we were in complete lockdown, I think an immunity passport would have been a step forward. I’m not sure it is a step forward now. Maybe it will be a step forward in the future before we get a vaccine. If we wait until a vaccine, there’s no point in having an immunity passport then. The situation will be resolved then. The question is what we do until we get there.
One thing that’s really important to think about is the opportunity costs. What’s involved in actually taking this from an idea to a reality both just in terms of the legal complexity, all of the science, the boots on the ground and making this etc. I think we really need to think about the time, talent and resources required to make that a reality and where might that be spent otherwise.
In the short-term, I’d rather see that money spent on public education. I think we do know that a number of the public health measures work and we need to continue to remind people about things like social distancing, increased hygiene, use of masks, whatever it is that we learned from a public health point of view that is helpful.
Beyond that, we need to invest a huge amount of resources in contact tracing. We need to think about the ways in which we can use technology and do some really innovative things that are respectful of privacy but that can allow people to meet their obligations to the broader community in terms of things like contact tracing. I’d like to see a reasonable amount of resources put into vaccine development and treatments, we have so much on so many fronts on which we could be using the resources available to us that I think in the short-term immunity certificates are a distraction.
I think I would be advocating something very different if we did have a vaccine, if we did have knowledge because I do think one of the really strong arguments against exploring and investing in this app this time is we just don’t have any firm knowledge about the presence of antibodies and the levels at which they’re needed in order to give us any kind of assurances with respect to the risk of re-infection and to how long that immunity will last.
I know the data will keep changing and it’s very hard to work with shifting sands, but based on what we know today, I’m asking people to pay attention to the opportunity costs and to think really clearly about where you want to invest your time and talent.
I really do want to stress that I very much appreciate the tremendous pressure on governments right now to be delivering the appropriate and proportionate responses.
My overarching concern and again, speaking a UK context, is that while there has been tremendous pressure in terms of how to deliver the appropriate responses at the right time, we are really taking a very disjointed and ad hoc approach to testing the effectiveness of each of these measures. We had a lockdown, we have eased measures drastically, so this is a missed opportunity for us for instance to test specifically what particular measures are the most effective in terms of how we should be easing restrictions.
My concern is we have a rush to delivering measures. The case study here is the contact tracing app here in the UK. There was confusion about what model we would adopt and who has access to that particular data. It has taken up a lot of time and resources and what would be most helpful would be if we were doing this in a collective holistic approach and if we had a lot more oversight in terms of monitoring the effectiveness of all of these measures and how they’re feeding into each other.
I was part of an initiative that was put forward by a group of academics, led by Professor Lillian Edwards, for a Coronavirus Safeguards Bill. I really do think this is the way forward in terms of taking a more medium-term to long-term view of the coronavirus. It’s not going anywhere. It is very much here to stay with us in our societies and as the science develops, we should also be developing the legal and oversight responses to that.
I think the confusion is very misleading for the public and that leads to big questions about public trustworthiness. At the same time, we also need to take into account the impacts for equality and the impacts on power asymmetries in the employment context.
There seems to be a huge push towards the utility of particular measure but there does seem to be a real lack of joined up thinking and regulatory oversight and I think if we did introduce a regulatory oversight body that could be a co-ordinating hub for the other relevant oversight bodies in this space, that would be incredibly helpful.
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This has been reposted from the Ada Lovelace Institute.