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In the Bubble: On the Frontlines
All Podcasts Toolkit: Will I Need a Vaccine Passport?

Toolkit: Will I Need a Vaccine Passport?

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Description

Dr. Bob teams up with NYU medical ethicist Arthur Caplan to tackle your questions about what exactly vaccine passports are, when they might be a reality in the US, how to make sure they’re handled equitably, where you’d need to show them, and much more. Dr. Bob says vaccine passports will dominate conversations this summer, so get ahead of the curve and dive into the topic right now with this Toolkit!

 

Follow Dr. Bob on Twitter @Bob_Wachter and check out In the Bubble’s new Twitter account @inthebubblepod.

 

Arthur Caplan is on Twitter @ArthurCaplan.

 

Keep up with Andy in D.C. on Twitter @ASlavitt and Instagram @andyslavitt.

 

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Transcript

SPEAKERS

Arthur Caplan, Dr. Bob Wachter

Dr. Bob Wachter 00:07

Welcome to IN THE BUBBLE. I’m Dr. Bob Wachter. Well, ever since the first reports in early November that we were going to have effective vaccines. I had immediately became clear to me that the issue of the summer, once there were going to be enough vaccines out there for people to choose to get vaccinated or not. The issue of the summer was going to be vaccination passports or vaccination authentication. In other words, will people need to show proof of vaccination in order to access something? It is happening pretty fast, in part because the vaccine rollout is moving along pretty swiftly, in part thanks to our friend, Andy Slavitt.

Dr. Bob Wachter 

And it is relevant to all sorts of public settings, whether it’s travel to or entering a restaurant, or a hotel, or a theater, or a stadium. And it’s got, it’s a multifaceted issue. It has elements that are related to an individual, like, if it’s me, and I’m vaccinated, I’m going into a restaurant where everyone’s going to have their masks off, really would love to know that everybody in there is vaccinated, that might make me more comfortable going. So there are kind of individual issues. But then, just as importantly, there are societal issues we all have an interest in reaching herd immunity in getting to a point where enough of the population is vaccinated that the virus cannot find a toehold where we are.

Dr. Bob Wachter

Whether that’s locally or in the United States or around the world, and slinks away and defeat. And it may very well be the only way that we reach that point of herd immunity is to provide some level of incentive for vaccination or disincentive for not being vaccinated. The issue of vaccine passports is probably not going to reach a fever pitch in the United States until vaccines are widely available, which we thought was going to be in May or June or July. But now it appears that more and more states are opening themselves up to all people are eligible for their vaccine, California has announced that the all of the priority list will go away on April 15, everybody will be eligible. Many other states have already done that.

Dr. Bob Wachter  02:18

And it looks like there’s going to be enough vaccine for everybody, not by the end of May as the President has projected, but probably even a few weeks before that. So we’re going to find ourselves in May, certainly by June, in a situation where everybody who wanted to be vaccinated will be vaccinated and those who are not vaccinated will be people who have made a choice. And that will undoubtedly raise the issue of either businesses or governments enforcing proof of vaccination. So it’s already starting in Israel, as you heard on IN THE BUBBLE a couple of weeks ago, when we spoke to one of the top epidemiologists in Israel, which is maybe a month ahead of the United States in vaccinations soon after a large proportion of the population was vaccinated, they instituted the green pass where everybody has to show proof of vaccinations to have certain access to certain places.

Dr. Bob Wachter 

And even the United States just heard this past week that the Miami Heat basketball team is not requiring vaccination to get into the arena, but is going to open a vaccinated only section for fans to sit. And I think, you know, that’s the starting gun of the debate in the United States about vaccine passports. So the issue is massively complicated. It’s got clinical, ethical, legal, political dimensions. We thought it would be a great toolkit and the questions that came in from all of you were fantastic and interesting and as diverse as the issue. I wanted to have someone who could explore all of these issues with us, not just the ethical issues, but the legal and practical issues as well.

Dr. Bob Wachter

And there’s no one better than I know, at least then Arthur Caplan. So Arthur is the midi professor and the founding head of the Division of Bioethics at New York University, Langone Medical Center in New York City. Art is the author or editor of 32 books, yes, 32 books and over 600 papers in the peer reviewed literature. More importantly for us and I’ve known art for 20 or 30 years. He’s thoughtful, he’s academic. He is up on the literature, he’s produced much of the literature, he can see both sides have tough and contentious issues.

Dr. Bob Wachter  04:35

But he’s also not afraid to take a stance and unlike some ethicists, he’s also very, very practical, very pragmatic, and kind of gets the politics of it, which of course will be wild on this one. So Art seemed like the obvious person to help walk us through the ins and outs of vaccine passports and I was thrilled that we had an opportunity to chat. So with that, let us ring up Arthur Caplan.

Dr. Bob Wachter

Welcome Art, it’s great to see you and have a chance to talk to you. This is such an interesting time and a lot of ethical issues are coming up. So you are my go-to person to calibrate how to think about some of these. To me, this is a big one, this whole issue of immunity passport. So when people refer to a vaccination or immunity passport, so tell us a little bit about what they mean. Let’s start with the definition.

Arthur Caplan 

Well, the interesting thing about immunity passports is people mean many things by them. So traditionally, a passport is what you use to travel to another country. And it’s issued by the government. And governments sort of set the standards for what you need to do to get a passport, you may need to prove that you were born in the country. Or you may need to prove other things about yourself before they’ll give you a passport. So let’s say that’s the paradigm, a vaccine passport would be perhaps amended to a passport system, you would add your vaccine status, you might get an extra stamp in your passport, you might get an extra card to carry, that would supplement your passport.

Arthur Caplan  06:16

And that system could be what we set up. And I think we will be setting it up eventually for travel to other places. But a cousin to that is what I call Vaccine Authentication. That’s having something on an app or accord. I’ve jokingly said to people who’ve gotten their shots and gotten the little CDC card laminated because you might have to show it down the road, if you want to get into certain places, or even if you want to get employed at certain places.

Arthur Caplan 

So what that means a Vaccine Authentication is I’m going to show proof of vaccination, either for internal travel, I’m going to take a cruise, I’m going to use it to get into a particular service like a sports event, or I’m going to have to show it to go in a restaurant. Or my boss may say you’re not working here until I get proof of vaccination. So those are the two main ways to think about this, what’s going to be required internally, if anything, for showing COVID vaccination, and then what will be required to leave this country and go elsewhere, or for others to come in here.

Dr. Bob Wachter

Alright, let’s get to some of the questions. There were a lot of questions about legality of it. Let’s start with those and then we’ll get to some of the ethical and the practical matters. So Jaime asked: “which entities” here we go “government educational institutions, private businesses have the legal right to limit access to goods and services to those with proof of vaccination. I’m curious about any sectors of the US where this would even be possible?”

Dr. Bob Wachter 

Well, legally, we know that the government at the federal level has the authority to control who comes in to the country, and basically can require documentation or proof of vaccination of immigrants, tourists, and people who are here on what people familiar with the green card sort of workers that are coming in. The federal government’s authority is really the national boundaries. That’s where they can demand and we do ironically, people are often unaware of this, if you want to go through the immigration process, from another country, we have a slew of vaccines that you have to take, you can’t just come in here. So it’s already established. I don’t have to fantasize about whether that would work.

Arthur Caplan  08:37

But the mandates that we’re talking about for internal authentication and so forth, that states and it may even devolve, if you will, down to counties, or cities because they control what happens inside the US. We are still a federal system. And I can imagine that assuming, you know, let’s just make up a thing. A county declares, it wants vaccination proof in order to use the parks in order to use recreation, or in order for your kid to go back to high school say they’re 16 and up and they’re vaccinated. We know they have the authority to do that there’s already mandates in place that say, you cannot attend school unless you have proof of vaccination.

Arthur Caplan 

So I think it’s legally sound to imagine if the case can be made that vaccination is important to the public health and safety, that the vaccines work and that they’re safe, that they could be added to the existing state or local authority. The private one, I think is interesting. People may say, well, they can’t really make me do this or that. Well, the answer is yes, they can. We’ve already had an opinion come out from the Equal Opportunity Commission at the federal level that has said, you can mandate vaccines as an employer because they’ve been asked.

Arthur Caplan  10:00

What you have to prove is it’s necessary to the operation of your business, to be able to say to your clients, it’s safe, it’s protected, it’s an attribute of letting the company or the entity run and do its business. What you can’t do in private businesses, discriminate, I couldn’t say, left-handed people have to get vaccinated, or I couldn’t say everybody who comes from Cambodia has to get vaccinated at my company. But you can say, in order for me to run this business, I have to assure people that my workforce is safe, delivery people, used car salesman, whoever I come in contact with, and I’m gonna make that a condition of employment. And you absolutely legally could do it.

Dr. Bob Wachter

Simon, whose handle is @analyticfooty I want to know the story behind that.

Arthur Caplan

That’s a philosophical podiatrist.

Dr. Bob Wachter

I think that’s probably right. Yes, does this completely undermine the principle of medical consent?

Arthur Caplan

Well, that’s another great question. People sort of say you can’t make me do something that I don’t give my permission to do. Again, I don’t think that’s quite true. If we looked at what happens in the way of what we do with children, for example, we mandate vaccinations at birth for certain conditions, we mandate vaccinations for admission to school, even if parents say no, or don’t want it done. And there are many, many areas in our lives, where vaccination is done without consent. The most obvious one is the military. The consent you get in the military about vaccination is which are really, given a whole lot of choice.

Arthur Caplan

As soon as the COVID vaccine gets licensed, I’m predicting the military will be vaccinating. They follow sort of recommendations from CDC and other groups that these things be added to the vaccination list, and they will do it. And then you have other people sort of saying, well, wait a minute, there are other things that we do in life that we don’t consent to in terms of having to get a physical, or an exam. Some people know in the healthcare workforce, you have to show that you’ve been vaccinated against certain diseases, depending on where you work like the flu. So I think the pattern is there to say, given the public health need or the need to protect others, we will permit a waiving of consent, if you could justify the risk benefit of it.

Arthur Caplan  12:37

You mentioned something about when the vaccine is licensed. So let me ask you two factors that I wonder, I wonder how they’ll play into it. One is, is it important that we wait until the vaccine is universally available to everyone, which we’re now told by the country will be in May? That it’s premature to think about doing this until everyone has access to the vaccine. And the second, is it premature to do this when the vaccine is available under emergency use authorization? Is it critical to wait until it’s been fully authorized?

Arthur Caplan

Yeah, both again, great questions. Let’s do the latter one first. So just so listeners remember, these vaccines are out, but they’re out under what’s called Emergency Use Authorization, which really means the FDA took a look at the data that came in on the vaccines and said, we’re not going to require you to take it all the way to the end in order to make these vaccines available. Because we are in an emergency, a pandemic emergency. Normally, they would have acquired roughly speaking, a full year, maybe 18 months of data on the safety and efficacy of the vaccine, but they approved much more quickly. There’s a variety of reasons why they did that we don’t have to get into that some of them they’re satisfied that the platform being used is very, very safe, because it’s been tried some other vaccines.

Arthur Caplan  14:04

But in any event, it’s not licensed. It’s out there. And as a kind of compassionate use for the world. We’re going to do something to fight the epidemic. I think you could mandate. But I think you’re in for a fight, under Emergency Use Authorization, I think people would say incomplete data and not a real product. I don’t want to do it. I think it would be even dangerous to try and push authentication or mandates or passports under an EUA because you’re going to get into a legal war that’s going to be there.

Dr. Bob Wachter

That’s what I was wondering legal fight or ethical/political fight.

Arthur Caplan 

Legal fight. I think ethically to do it. Vaccines are out there. They’re looking pretty good. I don’t think anybody’s dead from a vaccine. If you look at data from places like Israel, it looks like a lot of people are alive because of vaccine. So I think it could make the case and judges I think would take it. But I think you’re still in for that war. And that would really tie things up to the point where it wouldn’t matter, because it’ll take five years to get the issue resolved. So no one the EUA’s, I don’t think so. But once licensed, once we get data coming in, by the way, sorry, the lecture here, but that’s its own little sub problem, because it’s hard to collect that data, when you have emergency use, it’s hard to do the big trials, people drop out, people don’t want to get in studies.

Arthur Caplan

So it’ll know probably slow it down to the point where licensure may not happen till next year. So what we’re talking about here then isn’t just vaccine availability, but vaccine licensure. So I’m going to make a prediction, we won’t have this passport authentication, probably till the end of the year, driven partly by supply, it would be weird to say you have to do it if half the country hasn’t had a chance to do it. But it also I think, is going to be tough until FDA is ready to license, they may decide to license on less data than they usually have, or maybe other sorts of information following up people as opposed to putting them in a randomized trial prediction into the year.

Dr. Bob Wachter  16:17

It’s hard to shock me, but I’m a little shocked by that, because I would have thought that the issue would be everyone has had a chance to get it. And the timeline of everything has been sped up so much. I mean, these vaccines came out in 10 months, that would be the starting gun, everyone has had a chance to get it and some people are choosing not to. And now I’m trying to figure out do I open up the stadium? Do I open up the gym? And even if the full licensure is six months away, I think the debate is likely to start like at the end of May, don’t you think?

Arthur Caplan 

Oh that would agree with I mean, as soon as we see a, let’s say a high level of vaccination. I’m pretty sure the military will be vaccinating. I’m pretty sure the healthcare workforce, which already accepts mandatory flu vaccination, partly due to yours truly yapping about it for eight years. But it’ll be still fought I think if private businesses do it, that’s what I want to be challenged. It’s got a basis for the challenge. So you may see, here’s the world we might come to, let’s say I don’t know about May. But let’s say by June or July, we get a lot of people vaccinated, some businesses trying to impose it and demanding authentication of their workforces.

Arthur Caplan 

And some minority of people challenging that in the courts. Maybe the mandates still hold until licensure happens. You know, it’s one of these, we’re doing it, you fight us. But then the licensing comes through in the debate ends that kind of scenario. But there will be people who fight. And we’ve had this is unprecedented. The only time we’ve had an emergency use authorization of vaccine was for Anthrax for a small group of people, I don’t know, 5, or 6, 10 years ago, something. It’s never happened like this. So it’s hard to predict what the legal thing will look like.

Dr. Bob Wachter  18:04

But it sounds like you do believe that it is also it’s really important that vaccine be available to everyone that it’s premature to think about this before everyone’s had access?

Arthur Caplan 

Correct.

Dr. Bob Wachter

Alright, let’s move on to some of the practical ethical issues. Karen gave us a whole bunch of questions. Let me just run the group by you. And you can tackle whichever ones, you think they’re all of a piece. Basically, what’s going to be on or in the passport or in the authentication, will it list which version of the vaccine you receive, particularly if some versions are not as effective against some variants? What about people who’ve had COVID and therefore just got one shot rather than two? Will that be specified? They get raises a broader question about people who just had prior COVID where we think that they are immune at least for now. Maybe it’s not as durable, the vaccines better but at least as far as we know, they are still immune.

Arthur Caplan

Let me jump that question right now.

Dr. Bob Wachter 

Yeah, go for it.

Arthur Caplan 

Prior COVID it will not be a substitute for vaccination. I mean, it’s we don’t know what the heck is going on. Some people had prior COVID mild, they had little antibody. Some people had a whopper of exposure. It’s too all over the place. And I’m going to say that won’t substitute for vaccination. You can’t, you’re not gonna be able to say I didn’t need it, but I’m authenticated because I had it. I don’t think so.

Dr. Bob Wachter

That’s not gonna fly. Okay. She also asked, we already receive a vaccination card with proof of vaccination version batch number, how will the passport be different? If it’s digital, what kind of protections against fraud will be implemented and, of course the fraud issue is fraught everywhere. I mean, the idea that I’m going to take my little CDC card that I probably could have, you know, done up in the five and dime store across the street. And that becomes the thing that opens my magic door. That’s almost hard to believe. So how are you thinking about sort of verifying and the issue of fraud?

Arthur Caplan  20:18

True. So there’s two paths here. One is, the government answers some of these questions by standardizing and also gets involved in international discussions, to harmonize. This is the shot; this is when you got it. This is when you need a booster, we think you’re pretty good against 90% of variance. And you should come back and get that booster in 6 months or something like that, or the private sector. And there are companies already starting up to do this as we’re gonna set out those standards. And they’re going to be all over the place. And we’re going to either link it to your existing health record, when that be convenient, you’d like to be helpful. There are many people who would say, that’s great, you know, we’re putting in with my whole health care package.

Arthur Caplan

And if I go to the hospital, they’ll see I’m vaccinated and they’ll see my blood type. And they’ll know that I’m a diabetic and know, that’ll be great. Other people I think, are going to say, well, you know, I’ll do the private thing. But I just like them to have them vaccinated or not. And that’ll be plenty. And that’s all my boss needs to see. Each company will then say, here’s a forgery protection, each company will then say, here’s what we promise to do. In terms of disclosure, it’ll be a stew of many different private sector authentications. If the government tries to stay away, and the government, you know, even under the Biden, I mean, there was no chance the Trump administration will do this. But even under the Biden administration, they’re saying and the way they talk is they don’t really want to go here yet. I think they’re gonna watch the private sector for a while and then maybe do something.

Dr. Bob Wachter  22:02

Yeah, we had, you may have heard of this guy named Andy Slavitt. We had him on the show last week, I think he invented the show. And I asked him about that. And he I think, was pretty clear that the government doesn’t want their fingerprints on this in the short term that the private sector will do what the private sector does. And you raise an important point, the government may not be the mandator, but may be necessary to be the insurer that it is a system that’s reasonably accurate and reasonably fraud proof.

Arthur Caplan

Right. You know, in a weird way, we have a precedent here just on the internet with a company’s handling, you know, if you will, the dissemination of information we fight about whether they’re a journalism forum or just carriers when it’s Facebook, and Instagram, and all that government sort of stayed out. They don’t run those things. But they’re getting asked now frequently set standards, building more privacy protections, set out the infrastructure to make us comfortable about what’s going on.

Arthur Caplan 

That could be the future of the vaccine passport, or vaccine authentication, as well. We tend to like in the US, when the private sector does it and sort of goes out and kind of tries out different ideas. And then the government steps in, it’s a little different from the rest of the world where I think they turned to the government to set it up and then let the private sector implement.

Dr. Bob Wachter

We had one of the leading epidemiologists from Israel on last week and she talked about the Green Pass that they’re using there. And they’re you know, the government knows the health record of everybody, everybody’s in 1 of 4 HMOs you have a government health ID number, a hell of a lot easier than the Wild West that we have here.

Arthur Caplan

NHIS thing you can look at many countries, they you know, the information we’re fighting about protecting. it’s already in the hands of the government in many states. Let me point out one other thing, the fear about what the whoever knows things about your health status, vaccination, or whatever it is, is partly driven by the fact that people are worried that they’ll be penalized, they’ll lose their insurance, they’ll lose their disability coverage, something will be done to harm them. The odd thing about vaccination is it privileges you, let you get a job, gives you more movement makes you able to access things that maybe others couldn’t or won’t, if they don’t have proof of vaccination, in terms of mobility, and travel, and so on.

Dr. Bob Wachter  24:31

So some of the fear when people protest, I think is because it’s the older worry. If somebody knows this about me in the US, they sometimes use that information against me, whereas in Israel or England or other places, they’re all in the health system. They’re not going to get penalized. They’re not going to get their insurance taken away they’re in and that’s a different moral foundation, if you will, for you know, having something like a passport come in. I don’t think anybody in Israel blinks if the government says we’re going to add vaccination status to your health record. It’s sort of like okay, you know, everybody knows what it is anyway, but you’re not going to kick me out of health insurance one way or another I’m in.

Dr. Bob Wachter

Right, right. Yeah, although I guess you could see it as it privileges you. But for the person who’s decided they don’t want it, it de-privileges you if that if now I can’t get access to my workplace or a job or a theater or?

Arthur Caplan

I mean, it does. But there is a, if you will, the incentives to do it, are strong. Whereas for a lot of things, if I give my information out, the incentives to do it are weak, maybe even dangerous.

Dr. Bob Wachter

Sure. I was talking this morning to a CEO of one of these companies that’s in this business of trying to in the private sector, get the information and verify it and get it out there to entities that want it. And he made the point that the we might have a huge garbage in garbage out problem here, that the record of your vaccination is held in many, many different places. Sometimes it was transcribed by a human being off your card and your name is wrong, your birth date in some places is month and day in some places day then month. And I imagine there’s some sort of point where the ethics meets the practicality where if the data are so unreliable, it doesn’t matter if this is a good idea. We just can’t do it.

Arthur Caplan  26:26

I really think that is probably my number one worry that we started out, willy nilly, with, as you said, five and dime cards, and you know, people standing in a line outside of CVS, and they got vaccinated, they really have information. They really track these people. Do they have any database? I don’t know. That is a huge, huge worry. I think that’s a legitimate worry. That could hold up the whole idea.

Dr. Bob Wachter

Yeah, I have to say after talking to him, I was became a little less enthusiastic about it, because it’s gotta it almost has to start with good, reliable fraud proof system. And absent that, the rest of it can be theoretically attractive. But really problematic.

Arthur Caplan

Right, I mean, it may be to be frank, if that turns out to be true. We could be talking about the passport and the authentication at the level of boosters at the level of renewal. It may not happen even this year, because of that problem. But it doesn’t mean it’s impossible. It just means you have to at some point, standardize and harmonize.

Dr. Bob Wachter 

Dr. Shaw, at @shawphd asked “what happens if a vaccinated adult wants to enter a passport requiring space with an unvaccinated child? How do we avoid this becoming a de facto ban on children doing stuff with parents doing their stuff with children?” Sort of one way to break up families.

Arthur Caplan

And this a lot of bad jokes here. But I mean, it’s also depends on where you’re at. I’m old. So you tell me you’re not going to bring your kid into the restaurant I’m getting happier. Depends on where you’re at is that I think adjustments will have to be made, I think what you’re going to see is, hopefully, the incidence of the virus is down to the level where you take the risk that the two-year-old might have it, because you know, you’re in a vaccinated restaurant, we’re at the staff. And let’s say all the adults have been vaccinated, you’ll bear the risk is what I suspect is going to happen. It won’t be huge.

Dr. Bob Wachter  28:37

Yeah. Yeah. And it strikes me and sort of the moral equivalent of not rolling this out until vaccines are available to all if they’re not available to kids, then obviously restricting kids is impossible.

Arthur Caplan

Right. I mean, you may admit them, they may be carriers, hopefully they don’t, you know, acquire it and get some sort of long-haul problem we don’t understand. But if you had just that group, and everybody else pretty well vaccinated, could might be a risk level that people would tolerate in their ordinary, you know, going about their business and their existence.

Dr. Bob Wachter

All right, let’s shift to a few more practical and maybe more ethical questions. First of all, a lot of this is predicated on the notion that not only might it be a good idea for the individual, but that this will incentivize vaccination that we have a public interest in people getting vaccinated because of the notion of herd immunity. So maybe just as a practical matter, do we have any data on that question of, maybe there’s no analog to this exactly. But how much would this incentivize the person who’s on the fence to get vaccinated, any idea?

Arthur Caplan  30:01

I’ll give you a case example, I don’t have sort of empirical quantitative data but measles was kind of wiped out in this country when we had pretty good coverage. We began to see it slip and in small communities we created incubators because people really didn’t get their kids vaccinated. That led to a lot of anger, we had outbreaks at Disneyland and outbreaks in Minnesota and there were outbreaks in other places as well and there was a movement very interesting in California, New York, Maine and being debated now in Connecticut and Massachusetts to get rid of exemptions to control against measles outbreaks and they succeeded in reducing those exemptions listeners I will confess I argued against the exemptions and tried to get them removed both religious and what’s called philosophical which boiled down to I don’t want to do it.

Arthur Caplan 

So but I think that example is one where you can see people saying you’re putting me at risk it isn’t right my kid is going to get this or I even adults can get this, I want restrictions on your liberty because the danger you’re posing is too great to the community. So that may be an example recent one where in fact the balance morally of harming others, putting others at risk led people to say then you can’t exempt.

Dr. Bob Wachter

And the moral question I find very interesting because that community benefit is real in terms of reaching herd immunity, there is a point where if enough people are vaccinated this virus gets out of our lives maybe forever, maybe the variants change that. But the justification for authentication is partly about if I’m in the restaurant and you come in and you’re unvaccinated you put me at risk but what if I’m vaccinated and I’m really not at risk. What’s the moral justification to make you go ahead and get vaccinated if in fact the vaccinated person is safe and the unvaccinated person is basically making a choice, a health choice the same way that they might choose to smoke?

Arthur Caplan  32:14

Yeah. So the philosophical argument here was I think at least it’s attributed first to John Stuart Mill who I am an admirer of. And he said “your freedom to swing your arm ends at the beginning of your neighbor’s nose” meaning you can’t go around punching people. So the notion of restricting liberty does depend on the idea if you’re doing something that harms others we restrict, so if we’re all safe because let’s make up a number 80% of us all get vaccinated and we sort of are maxing out the community or herd immunity why are you pestering at that point the person doesn’t want to do it.

Arthur Caplan

There’s two reasons one is they still can become infected and they become incubators potentially of new strains or variants which we don’t want, same reason we’ve got to worry about what’s happening in faraway countries from the US perspective or the European perspective you don’t want nations to be places where new outbreaks with new strains occur. The other reason is no vaccine is 100% so even good vaccines the ones we see with numbers like 95% prevent death that’s amazing but it’s not 100% and you still could get sick you’re not going to die hopefully if you’ve been vaccinated.

Arthur Caplan

But it could take you out of work you could have let’s say a flu like illness for three or four days. If the harms none of those things turned out to be true the variants weren’t percolating and people said you know two days I get a cold like thing and stay in bed live with it then I think the case for requiring vaccination of those who don’t want to weakens it does start to weaken.

Dr. Bob Wachter  34:02

How do you think the politics of this is going to play out? There’s the Libertarian streak in the united states which is alive and well, we saw it with masks we’re seeing it now with opening up economies there’s all of that and yet in some ways the same party that has that Libertarian streak tends to be pro-business at least in its old version maybe it’s a little different today. So you’re an astute observer not only of ethics but of politics how do you think this plays out?

Arthur Caplan

So, politically when I’m trying to push for mandates in certain sectors trying to say you ought to require vaccination in the healthcare workforce or perhaps in certain businesses like cruise lines. And people get their backs up and say you can’t make me get vaccinated it’s just wrong it’s an intrusion on my liberty I sort of say well you tell it to the business in the private sector that is right there’s a weird politics here which is you want business to return, you want to go back to school, you want your kids to go back to school you want to go to college huh I think you may want to be pro vaccine even if you’re not but if you don’t like it fight it out with business.

Arthur Caplan 

I’m looking politically to see a division if you will in allegiance between give me my freedom conservatives like that, libertarians like that, return me the business, return me the public square conservatives like that too, you have to really take that seriously. I think politically mandating vaccines in terms of literal passports for coming in and out of the country, Slavitt, Biden, others may be saying I don’t know, they’ll be doing it soon enough. Countries are going to ask us to do it and we’re not going to just say hey come on in from wherever we don’t care if you pro vaccination that’s not gonna stick I don’t believe it politically I mean they may hold out for a while.

Arthur Caplan 

Internal authentication and mandates big war, big war coming, and it’s tied up to something else, hesitancy. You can hear that I’m strong vaccine proponent you can hear that I think in many sectors it would make sense to require vaccination but you still can’t give up on education and persuasion they have to go hand in hand I don’t want to be in war. I would like people to say yes it’s good to get vaccinated and not have to force, coerce, compel, incentivize just get them to think it’s the right thing to do because it works and it’s safe so I would like to see us be ready in this political battle to spend more than we’re planning to spend on persuasion through initiatives being an asset at the federal level to address vaccine hesitancy.

Arthur Caplan  36:45

I think it would quintuple them I mean I think that’s you know we want to get that last hump achieved where we’re kind of overcoming hesitancy and resistance fueled by many concerns but that’s the politics as much as we’ve talked you know about authentication, mandates, passports, you don’t really win this until people their hesitancy seen their fears are addressed.

Dr. Bob Wachter

Yeah and it’s fascinating just in the last few days it’s become clear that the groups we worried about hesitancy in largely communities of color that seem not to be all that hesitant. The groups that are hesitant seem to be Republicans and particularly Republican men.

Arthur Caplan 

I’ll give you one other group that people don’t like to talk about but, we do some surveying at the NYU medical ethics division. Women of childbearing age are still worried about fertility and they’re still worried about harm to the fetus and you gotta address that too. It’s a fear that’s out there, I pick it up because you know the workforce and healthcare’s got a lot of women, doctors, nurses, nurses’ aides, and I hear it when I ask people what’s your concern so I know we’re all worked up about the Tuskegee study and it’s a legacy, look communities of color angry about vaccination because they get treated poorly today. This system, too much racism. Those are the worries we got to address.

Dr. Bob Wachter  38:12

Or they’re treated poorly or you know in an effort is made to have the vaccine be accessible in their community and people have means come into their community to get vaccinated, is sort of predictable. Which gets us to Carlos Del Rio, who’s a wonderful physician leader in this area asked “how do we do this with equity?” So how do you think about the equity question as it comes to the possibility of these passports?

Arthur Caplan 

Well a couple of factors come into play here. One is, the wealthy and the rich still depend on the poor and the less well-off for many services. You don’t really want your cleaning lady not to be vaccinated, you really don’t want your au pair not to be vaccinated you’d like to get on a bus or a subway or an Amtrak train and have the person vaccinated it’d be nice to have your cleaning service people vaccinated at your workplace. I think the upper class will start to realize it’s in their self-interest to promote out vaccination heavily. We’re not you know we sometimes joke and say gee yeah disease that breaks out and you know Rwanda could be here in eight hours because we have planes and so forth.

Arthur Caplan 

A disease that breaks out like where you go to work could be in your house in about 15 minutes so you’ve got to really pay attention here and not just say well we made an enclave the equivalent of a gated vaccine community and we’re good the rest of the world can just be out there to put it briefly. The interest of the better off are going to drive them to want to protect the less well off.

Dr. Bob Wachter

Yeah. And you’ll begin to hear that with the discussions about global vaccination as well now. Feels like just in the last week has pivoted to I think it’s a sort of like the oxygen mask that once you feel like you’re okay now you put it on your kid.

Arthur Caplan  40:09

[…] Airplane rule. You’re gonna be helping your neighbor.

Dr. Bob Wachter

Yeah. But it you know, part of it is it’s a moral obligation to help your neighbor but part of the self interest in recognizing that you’re not safe until everyone is safe. Probably last question. This came from @CalamityJoey says something about his point of view with his Twitter handle. My only question is, “how soon can we start? And so I’ll reframe that to you. You’re obviously believe that this is a reasonable idea and passes your moral and ethical test, at least in certain contexts, which is comforting to me, because I also think it’s a good idea in certain places. What is your crystal ball tell you about how this will play out and whether it will truly become a thing in the United States?

Arthur Caplan

I think it will become a thing. I think we will see it for sure in international travel, period, end of story. It’s going to be there. You want to go to other places and countries by the beginning of next year At some point, they’re gonna do it. It’s silly to argue that when people aren’t going to want to see a vaccine certificate like a yellow fever card. I can’t. I just can’t imagine that won’t happen that way. Internally, my prediction is a supply increases. I keep thinking I don’t know about May, too many glitches, little slow on the rollout. But let’s say end of the summer, a lot of people vaccinated overcome some hesitancy so it’s available.

Arthur Caplan 

And we have the FDA perhaps saying we’re gonna license given what we know, fall on think you’re gonna start to see mandates in the military, mandates in the healthcare workforce, some businesses doing it to gain advantage to say they’re safe. So I think we’ll, we’ll certainly be in the fight about it in the fall. But I think we’ll see it mandates internal authentication, internal rollout. And then we’ll also be in the thick of the fights about what does this mean? And do we have the right information? And who should standardize it and what are we looking for? But yeah, I would say this year, end of the year anyway.

Dr. Bob Wachter  42:16

What do you think the likely businesses are to do? Is it you’re going to move?

Arthur Caplan

Travel, travel, travel. Cruises, airplanes, trains, you know, places where people are trying to get somewhere crammed together.

Dr. Bob Wachter

Great. Well, if you take anything away from this, there’s a lot to take away. But the first thing is go out and laminate your little card. There’s obviously plenty more. Art, thanks so much. You have a remarkable ability to discuss complicated things with great, great clarity and practicality.

Arthur Caplan 

And thanks for the quick questions and the listener questions. They’re very good.

Dr. Bob Wachter

Profound thanks to Art Caplan, as I hoped Art would be able to walk us through this incredibly interesting and complicated issue. And he did, it is so interesting on every level. And I you know; I think it will be fascinating to see how the politics plays out. You know, Art doesn’t think it’s going to become a super-hot issue until not only is there a vaccine available for everybody which is May, but until the full authorization we’ll see I think it’s going to become hot as soon as there’s vaccine available for everybody. And people are making a choice freewill choice to get vaccinated or not to but we’ll see how that plays out. I’m guessing we’re gonna hear more and more about that this summer.

Dr. Bob Wachter 

So hopefully you enjoyed that episode. We have a number of other great episodes coming up on IN THE BUBBLE. We’ll do one on how COVID has changed medical education. This is the world in which I live as a chair of a big department and part of what I do is teach for a living. We’ll bring on two trainees from UCSF one a resident Jack Penner, incredibly thoughtful guy, and the other is someone whose training has been altered and I’ve had a chance to watch it up close and personal. That’s my daughter Zoey, who’s just entering her fourth year as a medical student at UCSF will also talk to the dean for medical education at UCSF, Katherine Lucy, who’s been a real thought leader in this area.

Dr. Bob Wachter

While we’re talking about education, we’ll also do it quick check in with Zach Slavitt to see how he is doing in school. Another episode we’ll talk to Rhea Boyd, who’s become a national leader on issues of health equity, and COVID and talk about those as we enter this new and sort of getting near the finish line stage of the pandemic. Some of the equity issues are changing and it’ll be terrific to check in with Rhea to see how she’s thinking about that. Finely, the question of what to do about the kids has come up throughout the epidemic most tangibly in the form of schools. The school issue remains a huge issue but people are now grappling with camps, people are grappling with, you know, I’m vaccinated my kids are not, what can we do together?

Dr. Bob Wachter

Even the vaccine passport issue, as you heard the kids came up what if I’m vaccinated kids obviously aren’t because they can’t. How’s that going to work out in terms of someplace that requires vaccination so lots of new and interesting twists on the what to do about the kids issue and we will go back to one of my favorite experts, Paul Offit, who is a vaccine expert, but also a pediatrician, and we’ll pair Paul with a still to be named child psychologist to talk about some of the impact of COVID on the kids in terms of just how they’ve been doing and their psychology and what long term impact all of this will have on them and their development and overtime, so look forward to that as well. Great stuff. Until then, please stay safe and get vaccinated as soon as you have a chance to do so. And I look forward to speaking with you soon.

CREDITS

We’re a production of Lemonada Media. Kryssy Pease and Alex McOwen produced our show. Our mix is by Ivan Kuraev. Jessica Cordova Kramer and Stephanie Wittels Wachs executive produced the show. Our theme was composed by Dan Molad and Oliver Hill and additional music by Ivan Kuraev. You can find out more about our show on social media at @InTheBubblePod. Until next time, stay safe and stay sane. Thanks so much for listening.

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