In this episode we talking with philosopher and bioethicists, Voo Teck Chuan from the Centre for Biomedical Ethics in the Yong Loo Lin School of Medicine at the National University of Singapore.
We discuss the idea of Asian bioethics or bioethics in Asia, Teck Chuan's work on the ethics of immunity passports, and complexities of family and physical presence during the time of COVID. We also talk about the importance of ethics as a creative pursuit, not merely pointing out problems.
References
Art and Music
Undisciplinary - a podcast that talks across the boundaries of history, ethics, and the politics of health.
Follow us on Twitter @undisciplinary_ or email questions for "mailbag episodes" undisciplinarypod@gmail.com
In this episode we talking with philosopher and bioethicists, Voo Teck Chuan from the Centre for Biomedical Ethics in the Yong Loo Lin School of Medicine at the National University of Singapore.
We discuss the idea of Asian bioethics or bioethics in Asia, Teck Chuan's work on the ethics of immunity passports, and complexities of family and physical presence during the time of COVID. We also talk about the importance of ethics as a creative pursuit, not merely pointing out problems.
References
Art and Music
Undisciplinary - a podcast that talks across the boundaries of history, ethics, and the politics of health.
Follow us on Twitter @undisciplinary_ or email questions for "mailbag episodes" undisciplinarypod@gmail.com
Voo Teck Chuan: So obviously I think that of ethics as having a kind of creativity, right. As opposed to just pointing out the issue and saying, this can’t be done, that can’t be done. My, my response is, okay, tell me what you can do, tell me what can be done, you know, say something.
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Christopher Mayes: Welcome to Undisciplinary, a podcast where we talk across the boundaries of history ethics and the politics of health. Today we are recording on the unceded lands of the Wathaurong and Wurundjeri peoples of the Kulin Nation in Geelong and Melbourne.
My name is Chris Mayes, and I'm joined by my co-host, Courtney Hempton—I always stumble over these things—Courtney Hempton, co-host.
Courtney, what are we talking about today and who we talking with?
Courtney Hempton: Today we are joined by Dr Voo Teck Chaun.
Teck Chuan is an assistant professor at the Centre for Biomedical Ethics, Yong Loo Lin School of Medicine, National University in Singapore. He researches and writes on ethical issues arising in healthcare and public health, with focus on outbreak response and preparedness, and their intersections. He is a member of the World Health Organization Working Group on Ethics and COVID-19. So welcome to Undisciplinary.
Voo Teck Chuan: Hi Chris, Hi Courtney.
Christopher Mayes: Hi TC.
Courtney Hempton: Thank you so much for joining us. So as may be obvious from your introduction, we will be talking about your work on COVID-19 in particular, but also broader kind of issues in, in public health ethics. And so I guess I just want to begin, as we quite often do, thinking about your training kind of what led you to the work that you're doing now and kind of some of the roles that you have. So you did an undergraduate and Masters in Philosophy at the National University in Singapore, a PhD in bioethics and medical jurisprudence at The Centre for Social Ethics and Policy, and The Institute of Science, Ethics and Innovation in the School of Law, University of Manchester. So perhaps just as a starting point, I wonder if you want to expand on, on your interdisciplinarity, having training in philosophy and bioethics and jurisprudence, and I suppose if you want to discuss about some of the projects you've been involved with, or some of the current work that you do, particularly I suppose noting that your, your current roles are affiliated with the School of Medicine, so you're one of these people with philosophy training, who now kind of find themselves situated in the medical school.
Voo Teck Chuan: Yeah, so I did my undergraduate and masters in philosophy at NUS. And then I took a break, because I was burnout from philosophy. I went to work as a speech writer at NUS, for the NUS President. And then I got kind of, renewed my energy into critical thinking and there was a new bioethics centre, the Centre for Biomedical Ethics set up in 2007 at the medical school in NUS, and applyed as a research assistant, get a couple of years of experience learning a whole new language in medicine. Things like sepsis were, things were, were not things I heard off. And then I applied to do my, my PhD at Manchester under scholarship to work on a human body and its limits. And I did my PhD in organ transplantation and that's where the majority of my research was focused on when I was a research assistant all the way until, for my PhD. And I started thinking more about other things, particularly in public health, especially infectious disease control and management. So I've been working in these two areas, organ transplantation and more broadly medical ethics and health care, as well as infectious disease ethics, and kind of look at issues that are at the intersections
Christopher Mayes: That's a fascinating area and, different, yeah aspects and intersections to be working at. Something that we're interested in as well, and perhaps more broadly before getting to some of the specifics of your current research interests, but more broadly about the situatedness of bioethics, the situatedness of particular debates and medical technologies and their emergence, and how that I guess produces different kinds of social and ethical and political concerns and responses, so one, you know, noting that you have, did your PhD in Manchester, that you are working in Singapore, and then there's these different debates around bioethics in Asia or Asian bioethics, and if there's a particular Asian character to bioethics, and similarly the project that we're working on with bioethics in Australia, I think that's been this long assumption that bioethics is this American invention. Alastair Campbell, who, you know, was that your Centre there, I think helped establish it, he wrote a quite a fun critical and funny review of Al Jonsen's book The Birth of Bioethics, where he talked about that American view that the only type of drink is Coke and the only type of chicken is Kentucky Fried Chicken, and so it's just replicated in different contexts. And I know you're on the editorial board of the Asian Bioethics Review, so it'll be interesting to hear your perspective on some of these debates around Asian bioethics, or bioethics in the context of Singapore and different regions.
Voo Teck Chuan: Yeah, right. Uh, yeah. So I guess Alastair coined a distinction between Asian bioethics and bioethics in Asia. So he was trying to sort of argue against this reification of various, sort of homogeneous thinking, whether in Asia or Western cultures, and never the twain would meet. So he was okay for a more multi-cultural and interdisciplinary approach to bioethics, where essentially scholars from here and then come together and talk and discuss things about issues that are important to the relative setting, as well as common concepts and how they might apply to their own setting, right. So of course there are scholars who would argue that, that there is a distinctive Asian bioethics in a sense, where we are more communitarian more, more collectivistic, we focus a lot on the family and its values, and how this might not play, play out in the same ways in, in Western countries and things like that.
In my view, a lot of the arguments are logically debatable. So the fact that we value family, the fact that familial identities constitute our identity and so forth, does not mean that you say when you break that news to a patient, you could still tell the patient first and allow him to sort of decide how to share the news of his family, empower him to be empowered by his own family, right, getting a family together, talk about how treatment and care could play out, rather than as some people argue, against Western bioethics, that essentially you know in Asian settings, which is very multicultural and heterogeneous, that we should always inform the family first, and the family would decide how to tell a patient, if at all, and then a family take care of the patient and so forth. So I think there's a, when Alistair was arguing for a bioethics in Asia with, rather than Asian biotics, he was arguing for a more kind of a pluralistic approach to understanding bioethics, a more inclusive approach. So there are many views from everywhere and nowhere right, and you have to be situated in your particular setting in order to understand how values that seems to be universal, like respect for persons, could be concretised and apply in our own particular system.
For example, right, so even in Singapore, there are, we are, our laws, for example, right, our common law, well, it's based on very individualistic, kind of a systems from the UK, right, because we're colonised. So you can't, you can’t say that, you know, we are Asian we approach informed consent in different ways we break bad news in different ways. There is still that system too but, but even you tried to fulfill your basic requirements of informed consent to the patient as opposed to the family, there are ways in which you can bring the family into play, to sort of support the patient.
Christopher Mayes: It's interesting, you're bringing up that sort of legal and constitutional history of Singapore and then what gets, what can be called Asian and based on what categories. So in the past, we've had a prime minister and different people within Australia say, oh we should be Asian, and consider ourselves Asian based on geography, and that's sort of, I guess one category by which to sort of group a people, or society or culture, based on these sort of geographical proximity. But then, as you point out, even Singapore, which is clearly very geographically proximate to what is Asia, then has also this overlay of this colonial legal structure that would also shape a ethical and legal understanding within the medical context. And, and I think also this idea of the homogeneity both of Asia, and then the homogeneity of the West, needs to be, you know, questioned and troubled around, perhaps over emphasising that autonomy, the individual, play out in isolation of the family or community concerns, is also something that perhaps doesn't hold up when looked at closely.
Voo Teck Chuan: Yeah, I mean, even for the concept of solidarity. So I've heard people say that solidarity is a very European concept, doesn't really apply to the US. Ah, but, uh, so I'm part of the Ethics Advisory Committee for the University of Nebraska, Global Center for Security, a little ethics group working on COVID-19 issues as they play out in the US, and I've always heard this term solidarity being used, so they do look, a very, more collective community approach, solidarity approach. So I guess it's all just values and potential systems that could get us together to live well together to, to fight common threats together, as opposed to saying that this applies there, and this doesn't really apply here, you know, it doesn't make that much sense to me.
Christopher Mayes: You, you brought up COVID in that context. And I suppose these debates do play out a lot as well, at least I'm seeing them, or these stereotypes play out in the way that different examples are brought up, so Australia, for instance, people will often compare our responses, whether successful or otherwise to other European, American, or say Swedish, as the other sort of counter examples to what path Australia should be going down. And then there may be a sort of response that things that happened in Hong Kong or Singapore or South Korea, they are operating in a different ethical or social or cultural context that isn't as applicable here. So again, I think the sort of stereotypes of authoritarian, communitarian responses work in those countries, but not in Australia where we are sort of autonomous, freedom loving individuals.
Voo Teck Chuan: Yeah, I think you can see it, I think in a way in which various countries, approach the issue of mask wearing, or face coverings if you like. So I guess it's been pointed out that in countries like South Korea, Hong Kong, maybe even Japan and Singapore, that we were more inclined towards wearing masks as the governments, as our respective governments are advised us, or make us, make it compulsory for us to do so. Uh, but I wonder if there's much more, less of a matter culture, it could be a matter of culture I guess, people in Japan, people in Korea and Hong Kong, but not in Singapore, they have been used to wearing masks, even for influenza cases, right. So if you have a flu, you're going out, it's regarded as polite and protective of others, that you wear a mask to prevent your germs from spreading. So now, maybe it's easier to institute, but we never had a mask wearing culture in in Singapore, despite our proximity to these countries.
And, besides, being largely Chinese in ethnicity, right, so when, when it happened in Singapore, I guess this partially has to do with historical memory of what happened with SARS, so there's a lot of trust in a government on what is to be done. There's a lot of trust in science, there's a heavy emphasis in science and Singapore in terms of education all the way from the lower education. So we realised that a things, I mean, SARS-CoV-2 could be spread by asymptomatic patients, people, that's when we realised that we actually need to wear a mask as we go into the community settings, and not just in healthcare settings. So I don't know, I wonder, if this sort of very pragmatic approach, rather than cultural approach, very scientific, trust are the particular values that will sort of drive people to endorse or to accept what government advise, right, assuming that you have a benevolent and trustworthy government, I think that might be where the difference lies.
Courtney Hempton: And perhaps just for my own knowledge, maybe something I should have Googled before we started this conversation, what is the kind of COVID context in Singapore at the moment. So, for example, I'm in Melbourne, I'm still in stage four lockdown, so we have mandatory masks and things, but I have higher restrictions than, for example, Chris, who's in regional Victoria. So I'm just wondering what the kind of context is in Singapore, at the moment, or that you're kind of living in?
Voo Teck Chuan: Well, we think about, we use a very unique term, we call a circuit, circuit breaker like trying to stop the flow of electricity, we try to stop the flow of the spread of the virus. So its a kind of a euphemism I suppose, and we have different stages, we’re now in what we call phase three or phase two, where there's a lot more freedom. You can gather in groups in restaurants, but not more than five people, children are back in school by the they have to wear a mask, for adult learning, say in university teaching, you can if it's necessary to do face to face teaching with mask and protective shoes on, and things like that. But most university teaching is conducted via Zoom, I guess, like in many places. So, essentially, the key difference, I think, is, is that when we go out and we go to any of sort of communal place, like a mall, we have to sort of do a safe entry, key in, so you have t use the app, you do a QR code, and that will record the entry into, into the place, and we have to wear masks in the community. So that's what's been happening in Singapore, of course, you're doing, if you're exercising outside, you don't need to wear a mask, like cycling, that’s why bikes sales are going crazy in Singapore, because if you're cycling you don't have to wear a mask. Yeah, so that's the current state, state in Singapore.
In terms of infection cases, we are in the low twenties, now. So we kind of separate, so if you might know, that there's a contagion, I suppose you know in our migrant worker population, where they live in dorms and that's how things spread so fast, so they are counting things differently for the migrant workers, the construction workers versus the rest of the population. So just a little, the rest of the population, citizens and residents, it's been about less than ten or five or sometimes has been zero every day, but for migrant workers its still about maybe 20, 50, somethings 100, everyday yeah, but that's considered good, yeah, whatever good means.
Christopher Mayes: It's interesting, your comment earlier about trust in the government and in the, in the process. I think something that we're seeing and have been seeing here is this attempt by various groups, some of whom are politicians, and some just working in the media and other areas, I guess eroding trust in, even in the process where we are seeing case daily case numbers go down as a result of as, as a result of the measures being put in place, like there’s sort of clear evidence that things are, well, relatively clear, because now there's questions about whether test, the same level of testing is going on, but it regardless, I guess the, my question or, and I’d be interested to hear you on, is whether there are, in your context, people in the media or elsewhere sort of eroding trust in the process, or questioning by pointing to other, other events that are going on, whether it's the economy that is suffering as a result of the measures that have been put in place, or saying things such as people in say aged care facilities or other facility, or loneliness and suicide, these are the unintended consequences of the measurements, are such that it is calling into question the legitimacy of, say, for instance, reduced time of seeing friends and family.
Voo Teck Chuan: Yeah. I think that might be two questions.
Christopher Mayes: There are probably about six, sorry.
Voo Teck Chuan: At least two, I guess. So I guess the first one is about ordinary people spreading, or maybe even reputable people spreading, disinformation, fake news and misinformation and things like that, right. So in the Singapore context there is less so, because we have rather strict laws on spreading fake news, and in fact, the government intervened using that particular legislation to stop people from putting it on Facebook and, and comanding Facebook to take down those fake news. There was a particular incident where people were clamouring in fact for wearing mask, that at the very early stage of the pandemic, because they were seeing it being adopted in other places, they were saying that, surely it makes sense for us to put something over our face to protect ourselves, although mask is more for protecting other people right, as opposed to be yourself, even though it goes both ways. And so the government has come out and say you know we, we go, work by, by evidence and by logic, and there isn’t any sufficient evidence now that in community settings we do need mask. So there was a bit of a debate about that, but I guess there in lies some, some wisdom, even people, about preventive measures.
And then in terms of the uh, I will say sharing our suffering and a negative impact, and in questioning the necessity of the measures, right. Uh, I guess one good thing about the Singapore situation is that, I guess we are a rich country, and we do have a lot of resources saved up in international assets and elsewhere, and so the government has been giving quite a lot of compensation, well not compensation but a financial support to many people, including for people who are working in, in the gig economy or what we call freelancers, so they are not bound to any contract or permanent position. That the government is also rather smart, in the sense that ot created new jobs, so we have what we call safe distancing ambassadors, so, these are people going around and making sure you wear a mask properly, if not, you'll be fined.
Christopher Mayes: I had an encounter with one today. We have them at our university now.
Voo Teck Chuan: Yeah. And the other thing –
Christopher Mayes: They’re called ambassadors too, it’s a funny choice, a funny choice.
Voo Teck Chuan: Goodwill, diplomacy things like that…
Right, so the other thing that was done, I guess, is to shift in very affected sectors to other sectors. So when airlines were down, they shift at the stewardesses to health care, to provide services, so that's one of the strategies they did. So, I mean, nothing's perfect, but we do have, I guess the political will, as well as the resources, to carry out some measures to mitigate the burdens.
Not everything is mitigated, of course. There are people who have lost jobs, were finding it hard to find jobs, but I guess that's been something that's been going on worldwide.
Courtney Hempton: And this conversation is probably a good segue into some of your recent work that we’re keen to discuss. So you were the lead author of a paper titled ‘Ethical implementation of immunity passports during the COVID-19 pandemic’, and that was published I think at the beginning of September in the Journal of Infectious Diseases. So I'm really interested in this kind of world of immunity passports, so I guess, just interested in your reflections on you know some of the scientific considerations, kind of where even are we with the science of being able to kind of inform something like an immunity passport, and obviously the broader kind of ethical, political considerations that we would need to be kind of cognisant of, if we were moving towards having policies, or introducing immunity passports. So, um yeah, perhaps just as a starting point, maybe explain, for those of us who aren’t across what, what an immunity passport is, kind of how they work, who are they for, what do we know about them, what are some of the potential kind of things we need to be aware of?
Voo Teck Chuan: Yeah, right. So, it's very funny story behind it, writing that article. It was my colleague from public health who approached me to write that article, and I don't even know what serological tests are, which is a means for detecting antibodies, so as to sort of test whether you are you have gained some sort of protective immunity towards the coronavirus. So immunity certificates or passports or licenses, as many people term it differently, are essentially health documents or records that certify that you have natural protective immunity towards SARS-CoV-2 reinfection, based on some form test. So the most proposed tests will be antibody test, or serological test, so they test for a particular form of antibodies which are supposed to be neutralising, that means to prevent they virus from entering your cells, and if you have the kind of neutralising antibodies you're supposed to, you’re assumed to have some level of protection.
The thing that we, I guess, scientists are not sure. So I'm not a scientist, but this is based on what I've read, is that nobody knows the, the true extent and duration of protection, so even if you may be protected, protected at some level, you might be still contagious, and even if you are protected it's not clear how long you might be protected for, right. So these are the key issues. There are also issues about the test itself, how, how reliable they are. So my public health colleague, you know, he's been carrying out these tests on a particular population, and the results come back, he doesn't know, really know what the mean, actually, that's what he tells me, right what does, what does it suggests about the protective, protection for this population that he, he's testing. Another issue I guess is the threshold for false positive, that means people who are tested positive for antibodies but in fact do not have the kind of antibody threshold levels, right, so any form of testing is not perfect, there’s always false positives and false negatives. And so you need to sort of determine the threshold of risk that you're able to accept right. So I guess, the lower the risk level, the less risk of people who do not have immunity but are walking around assuming that they have, and perhaps posing a public health risk to others, right, based on certain behaviours, after learning that they have no immunity. So that is the basic idea.
So essentially the idea is to sort of test people who are, who have recovered, or anyone who's interested to take a, an antibody test, and if they show the necessary level of threshold, and we understand what that threshold means, then the person can use that health record to exempt themselves from particular restrictive measures they can, for example use that as a kind of passport, to go through airports without then, arriving at the other side, without then having to go through some sort of quarantine, without having to do a swab test before you leave, for example.
So this is essentially what is being positioned for immunity passports.
Of course it goes beyond just interstate or international travel. You could use a, presuming that the science works, that the science is robust, you can actually test specific population or sectors, like healthcare workers, and so decide who might not need PPE, for example, or protective, personal protective equipment. Or you can sort of, provide them some assurance that you know they are no longer at risk, or at very low risk, low risk of being infected, and so this could help assure them psychologically, as well as their families.
Courtney Hempton: One of the things I find, I found really interesting, which is, I think, something that you mentioned in the paper is, I guess, the irony of how this works. So you're, if you've kind of been infected with, with COVID, or have this kind of immunological fitness, you're now kind of in this, I guess, protected group, where its people who haven't had been exposed to COVID, who are, who wouldn't I suppose qualify for, for these passports, which is kind of interesting, and not necessarily how we normally think about, about other kinds of diseases. But I suppose I guess what I'm just wondering on your thoughts on, I guess, you just mentioned some of the kind of possible benefits for particular populations, healthcare workers and you know benefits for travel and things, but I suppose what other, I guess some of the potential harms of moving towards having, having immunity passports.
Voo Teck Chuan: Yeah. So I guess the, I guess the biggest risk to individuals in society is the stratification of people into different risk profiles. Right, so you might have one group that is regarded as very low risk or no risk at all of developing COVID-19, so they can move around very freely in society, whereas the other group they can’t move as freely, they are subjected to various kind of restrictive measures that have very bad effects, they might be discriminated against because they are, lack that kind of certificate, or they may face particular stigma, which is very interesting because stigma usually attached to people who had had infections, as opposed to those who have not. So these are kind of, and of course there is risk of governments collecting data, and intruding your privacy and tracking you and so forth, right. So these are kind of various concerns that we might have.
If you look at the literature, you will see there is, at least for those who are for such a approach to easing restrictive measures on our lives, they have proposed many methods and measures to sort of mitigate, if not to prevent, these sorts of harms and risk. So, for example, for privacy, there's a lot of talk about developing applications and using blockchain technologies to ensure that you are in control of your data, as opposed to a third party or the government, so in fact if, as far as I know, Estonia might be the first country reportedly to have developed such an application to support blockchain applications of immunity certification. I guess the reason they, they do is they envision it as a plausible way for people to move around in society, interact others, even after a vaccine is developed, right. So you may have two groups, people with the vaccine, people who do not have the vaccine and do not have immunity, and the people who won’t go for the vaccine for some reason, or do not want the vaccine, or can’t go for the vaccine, but have immunity. Right, so there are, are still some uses.
In terms of stigma, one interesting issue is, again, back to mask wearing, so do you want to make people without immunity, do you want to maintain that they still wear masks, whereas those with immunity won’t need to wear a mask, so you have this very social division. And, you know, potential harms, even violence if people who do not have immunity do not wear a mask when they’re supposed to, and you know, and there might be subjective to some harm. So you know, various government regulations, policies, education need to come in for this immunity passport approach to reap the benefit it is supposed to and, and prevent the harms from happening.
Christopher Mayes: Is that also, the I guess risk and potential harm, for people to intentionally contract COVID for the purpose of then, or in the hope to become immune. So there's a, there was this idea, apparently it's a media myth, but coronavirus parties in the US, people going there to get coronavirus, apparently they were just parties where people got coronavirus as opposed to the intention of getting, or spreading, but you see it I guess with things like chickenpox, you know that people will organise that of chicken pox parties for their children. Fortunately, I never went to one of those, but anyway, yeah, and the potential that, as we're seeing where some people may have some underlying condition that they're unaware of contract COVID, and then it's not just a matter of, you know, having the flu and being a bit sick for a week, but having significant health effects.
Voo Teck Chuan: Yeah, so it's not just underlying conditions. You can even happen, and you can suffer a real harms, and maybe even death, for healthy individuals if you contract COVID-19, depending on your health system, whether or not they apply oxygen therapy early enough so that to make sure that your system is working, and whether or not it has sufficient drugs and ICU resources and things like that. Right. So there was, in fact, I think someone being reported having died from COVID-19 from attending and being infected at, while at these COVID-19 parties, right. So there's a real risk of perverse incentive right or, of deliberate self-infection, I guess, though, so the proposed method to mitigate this is to target your testing on particular sectors, especially those that are essential. So you, you don't apply it at a, at a community general level, you only apply it to particular populations, like health care workers or food, people who are involved in food delivery, and so even if you want to get a serological test that might be more limited, sort of access, unless you have very good reasons. So that's one possible way.
But again, I guess the counter-objection is it would sort of violate people's rights, you know, if you, you’ve already been infected, why, why can’t you take serological test and, and exempt yourself, might not make sense from an individual viewpoint. So I guess the real balance to that is making sure that people who are not immune certified, whether it's because of natural infection or vaccine, do not suffer disproportionate burden just being, just in virtue of, of not having any sort of immunity at all right, so you have to make sure that they have security, employment wise, food wise, health wise and so forth. So these are the kind of methods that, that I guess policymakers should consider before the implement an immunity certificate policy.
Courtney Hempton: One of the other possible risks that had not, didn't occur to me when I was first thinking about immunity passports, which you mentioned your paper, is kind of um, I guess, the risk of fraudulent behaviour. So, kind of, whether it's around, I guess at a testing level of somehow counterfeiting, your, your certificate. I'm just wondering, yeah, in terms of those kinds of, I guess, behavioural risks of these kind of perverse incentives around having some kind of passport or certificate system, how, yeah I guess the potential risk of that playing out, and whether that's perhaps different in either different kind of populations within a given country or perhaps, you know if we're thinking about this on an international level, how much something like an immunity passport actually kind of work, if it's requiring, it seems to require kind of trust and privacy, at kind of multiple, a multitude of levels, and how that might kind of actually practically be implemented.
Voo Teck Chuan: Yeah, that's a very interesting thing. But I guess the first thing to consider is, you know, in any exam there’ll be cheaters, a percentage of cheaters, so even for, so we have under the International Health Regulations, the requirement of Yellow Fever vaccination for endemic countries, right, so, even then there's fraudulent vaccination certificates being used at times, and in the context of COVID-19 in some countries where a negative test for present infection needs to be presented before you're allowed to travel, we’re seeing in some countries, people in some countries are being issued with fake certificates right, and doctors are being complicit in such behaviours. So there's always that kind of risk, and to some extent you can, you can sort of use technologies, you can link your test result with your biometric, or some sort of digital identifier, so that it can’t be transferred easily from people to people. But I guess it kind of applies to high income countries, and so if you are applying immunity certificates at an international level to travel, you will need both sides to have such technologies in order for such risk to be prevented or mitigated, right.
Again, it comes back to, when is such a requirement for you to gain some sort of access to an important project in your life. For example, so the reason why, that was in Indonesia, actually, where the fake certificates were reported, because they had to travel to different parts of Indonesia for a religion, religious event, so it was very important for them. So you have to think of multiple pathways right, as a, if I was a policymaker, when it comes to COVID-19, I would think of multiple pathways for people to travel to travel, for example, so if you have an immunity certificate you can travel but you don't need to be quarantine, as I mentioned earlier. If you do not have an immunity certificate or vaccination, you might need to take a negative test for infection, right. But you have to be subject to some sort of quarantine after you before, after they arrive at the other place. So these are the kinds of things to ensure that, to sort of reduce the disparity in terms of benefits between those who have, and those who do not have
Christopher Mayes: I guess you meant, you mentioned policymakers, and if these things are to be implemented, then they would seemingly need to be some kind of international agreement to these tests, whether it be through the WHO, or some other organisation, you know, similar I guess to the passports that we use for travel today. Have you been, because you are working on a panel with the WHO around COVID, has this discussion come up in that context, about immunity passports and how would be governed and regulated?
Voo Teck Chuan: Yeah. So, members of the group together with external members from all over the world, we have gathered together to write a paper, stating the position of the, of that group’s thinking on immunity certificates, and that will be published in the WHO bulletin very shortly, if I, if I'm right. So essentially is about what I've been saying here, it's not an endorsement of, to be clear, it's not endorsement of immunity certificates, right. So the WHO group has also published another document on human challenge studies, I'm not sure you know that, and so that's when people deliberately infect themselves in order to develop vaccines, and that is also not a position which we are arguing in favour of human challenge studies right. And neither, this paper itself is not arguing in favour of immunity certificates, but the positions that you would implement immunity certificates, you have to take account of all these various considerations and, and approaches to sort of mitigate the harms and burdens, and take account of very serious risk. Yeah.
Courtney Hempton: I just want to ask briefly because, and you mentioned Estonia, and when I did a very surface level Google of immunity passports and kind of what was happening, Estonia was one of the examples that, that came up that were trailing like a digital immunity passport, so it was like an app on your phone or whatever, and I just like, most of the articles where from May when this was, this was announced and being discussed. I was just wondering if you had any, I feel like in the life of COVID, May was aeons ago, I'm just wondering if there's been any kind of, I guess, further output in terms of, you know that, that trial, that’s happening in Estonia, if there’s any actually any useful information coming out of that trial, as to how these things might be working in practice or, or not.
Voo Teck Chuan: Yeah day to day I guess the scientific information comes in and, kind of contradictory at times. So you see papers been publishing that recovered individuals have antibodies, potentially neutralizing antibodies for up to four months, even after they have been infected, and those coming in that say that they have very weak antibody response. So there’s sort of, the, I guess the scientific picture is still evolving, we're not still clear. What they do know is that for coronavirus, based on the common cold coronavirus, based on the original SARS that in 2002, and based on MERS-CoV-2, that antibody protection is likely to wane over time, the only question is how long. They did find in SARS survivors, the original SARS, patients who still have antibody protection, even after decades, a good years after, maybe 17 years, I think. So they are still I think, trying to workout the understanding of how long infection confers in you a natural protection. And of course in order to know how long, you had to have time, right, you can’t know at this present moment, so they’ll probably track. I guess, practically speaking, if you were to implement immunity certificates based on imperfect scientific information, then whoever is issued an immunity certificate might need to go back for serological testing at regular intervals, right.
Christopher Mayes: So another paper that you've recently published in the Journal of Bioethical Inquiry, and it's quite interesting to think of actually the issue with immunity passports being one of regulation of space and movement, perhaps at a global on a regional level, and then this other paper at the much more micro and clinical or hospital level of, so the paper being ‘Family presence for patients and separated relatives during COVID-19: Physical, virtual, and surrogate’, and will provide links to these on our website and show notes, but, so this paper is looking at family presence or absence, the, the ability for family members to be with relatives who are infected with COVID-19 and in a in a clinical, primarily clinical context here, and whether there are opportunities for that physical presence, or whether a virtual or then a surrogate approach can be taken and yeah, I'd be interested just yet again if you could give a brief overview and origin, perhaps, of the paper like what drew you to this topic?
Voo Teck Chuan: Yeah, so, that paper has been making for five to six years. The original motivation for that was reading an article from Korea on a patient during the MERS outbreak there. So this is a lady who had to stay in the hospital, due to some sort of condition and she was dying, but she didn't have MERS right, and family having to be quarantined because they had been in contact, and because the woman was dying and they couldn't see each other, the husband wrote a letter to her, and a nurse had to read the letter to the lady, to the woman as she died, and they never got to see each other, and then after that her body was burned, and they never saw each other. So that is a tragedy to me. As, as I reflect on our own life, and you know what, what would be good to do if I was in that position, would I want my wife to come and see me, should I go, should the children go, and things like that, right. So these are kind of things that intrigued me. And then Ebola happened, and I see the same things happen in Ebola, and that was even worse, because these bodies were sometimes put in mass graves, they were burned. And then, of course, the WHO issued a guideline on that, on respecting the body and giving them dignified burials, burials that are safe at the same time. So, so I try to write something like that and, and that was finally published in the Journal of Bioethical Inquiry, and there’s another paper in Public Health Ethics that will be out shortly, and that is on the Ebola situation, whereas the paper in the Journal of Bioethical Inquiry is more for COVID-19, right.
So the idea here is actually is that, you know, how do we deal with the kind of distress, the grief, the adverse effects on children, especially if they're isolated and separates from their relatives, right at a time where, I guess a very scary time when people around you are all wearing hazmat suits because, you can’t see them, you’re, you’re isolated, they’re coming to take your temperature every time, right. So how do you sort of, firstly, what sort of comfort would a relative, a close one, a loved one be, if being present to you, as you stay in the isolation unit, and do you allow the person to sort of be at, the outside of the isolation unit, say hi to you, behind some wall, or should we allow the person to go in and be present to you. So I've argued that, in particular situations where say the patient's dying and there needs to be some last goodbyes, or when the child is a minor, a very young child, some relative like a parent should be allowed to stay with a family, with a isolated patient under, of course, the same sort of protective equipment as worn by healthcare workers. So but, in general infrastructure should be built such that you can sort of provide virtual presence, or e-communication, and that's been done in the US, there was an article, written by a medical student if I’m not wrong, or a very young doctor or intern, on how they have modified the system so that they can provide iPad, and that’s mounted on someplace, so that you know over the bed of, that patient can easily access to it. And that’s, so there's an argument to sort of ensure some sort of family presence for isolated patients during an outbreak situation. That was classified as an issue that lies, it's an intersection between clinical care and public health, right. So you need to take account of both sides, in order to sort of deliver humane care to patients, and the same time minding the public health risk of allowing people to so, to be so freely together at time when you do not, you might not know so much about the infectious disease. So as more information gathers, then this increases the justification for allowing family presence, because that's when you know how to control the risk.
Christopher Mayes: Yeah, I mean, there's, it's really interesting, and difficult dynamics in, in this in this space of infectious disease and, and these are these ideas of social distancing as a way to manage the disease, and then coming back to what I was mentioning in the Australian context with this sort of erosion of trust, or at least questioning the legitimacy and extent of interventions, when the, when the social distancing to protect the spread or transmission of infectious disease becomes so much that there is this social isolation, and, and, you know, talking about this more in the community context or here, and Courtney knows more about this than I, in that aged care context, where you know people talking about loneliness and dying of loneliness, but for the purpose of protecting. the transmission of disease. And then, yeah, your article which does touch on some very fraught and heartbreaking situations of end of life care in the context of highly infectious disease, and how that can be managed. And I think something else that you mentioned is then also the this role of the surrogate, if a nurse, in say reading out that letter, and the burden that potentially is placed on them both the psychological perhaps burden, but also the just the time if they're dealing with a, you know, an outbreak situation where or where there's a lot of things going on, to take that pastoral role on as well, can be quite burdensome.
Voo Teck Chuan: Yeah. So yeah, the argument, really, is about trying to change the default mode of containment, right. So when outbreaks happen, novel spreading in your community, you want to sort of take very controlled measure and, and ensure separation as much as possible, social distancing and physical distancing. And in, when it happened in West Africa, Ebola, it was taken to extremes, as I mentioned, and family started to, not bring in potentially infected relatives into care, because they're afraid, once these people go in they may not see each other again. So there were reports of people actually running away, going into bushes together and just being there, and to see whether or not the family member has actually the disease, right. And there were some positive cases where, actually, it turns out that the person who they brought to the bush did not have. So I, so even though there is sort of a humane purpose, harm prevention purpose, there is also these public health concerns that you have to think about, right. So what is the public health good if you were to allow family presence? And once potential good would be, you would incentivise people to report their symptoms, be more willing to go into isolation units and so forth.
Yeah, so I think this really speaks to the heart of ethics is about creativity, right. So a lot of people sort of just identify issues, but I think ethicists should go beyond that and actually propose some sort of solutions. And this actually happened, not by bioethics per se, but by people actually working in Ebola, they created a biosecure unit, very cheap to develop and, and that's where the patient is, is right in the village setting where the families are, and you have children, pulling out their seats, and sit next to their father and mother and just talking to the patient behind those, that biosecure, transparent unit right, and that is regarded as very safe, not just for the patient, but for everyone else. So you have to have creative solutions you can, you know, create transparent walls, even if your biosecure unit is not entirely transparent walls you can create a window, for example, that's where the patient, assuming the patient is conscious, can interact with a family members. So obviously I think of ethics as having a kind of creativity, right. As opposed to just pointing out issues and, and saying, this can’t be done, that can’t be done. My, my response is okay, tell me what you can do. Tell me what can be done, you know, say something. As they say in the army in Singapore, just don't give me, just give you problems. Give me some solutions.
Courtney Hempton: I felt like I've really enjoyed reading this paper, and I feel like I had questions, but also feel like that is such a nice, um, sentiment to conclude on. Um, I don't know, Chris, did you have specific questions, or…
Christopher Mayes: It's been a fascinating conversation, I really enjoyed it.
Voo Teck Chuan: Right. Thanks.
Courtney Hempton: Thank you so much.
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Courtney Hempton: That, that is the world we now live in.
Voo Teck Chuan: Yeah, sticking things up your nose.
Courtney Hempton: Yes.