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Vaccine passports are almost certainly in our near future. But what are they exactly? And with concerns about vaccine equity now complicated by partisan fear mongering, how should they be implemented?

Arthur Caplan, a bioethicist with NYU’s Grossman School of Medicine who’s spent years thinking about vaccine ethics, joins James Hamblin and Maeve Higgins on the podcast Social Distance to explain. Listen to their conversation here:

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What follows is a transcript of the episode, edited and condensed for clarity:

James Hamblin: Is there a concise way to just kind of paraphrase what the idea is of a vaccine passport?

Arthur Caplan: A vaccine passport can be broken into two distinct kinds of proof. One is an international document, just like a passport. You’d basically have governments issue them and use them to cross borders. [Vaccine passports would] either be appended to your regular passport, like a visa, or [be] an international document, like what we already have [with] the [International Certificate of Vaccination or Prophylaxis] used today by countries that require proof of yellow fever vaccination to get in.

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Domestically, the idea is for vaccine certification or authentication. That just means you have some way to prove to a business, private entity, or government facility that you’ve been vaccinated. That could be a card. It could be an app. It might be checking a medical record, depending on where you are. But, domestically, we have not had proof-of-vaccination requirements in the past.

Maeve Higgins: The vaccines haven’t been equitably distributed even within the U.S., and across the world. Do you worry about the vaccine passports magnifying that inequity?

Caplan: Well, as with everything around COVID, there are inequities that are always present. [President Joe Biden’s] administration has said right now it has no interest in issuing international vaccine passports. I will give them about six months before they do, because countries are going to say, “If you were to come in here, you’ve got to show us proof of vaccination.” And there will be countries that don’t have vaccines and that can’t do that. And people are not going to be able to travel from those countries into countries that do demand a vaccine passport for entry.

We may wind up demanding in the U.S., given our relatively fast vaccine rollout, vaccine proof to come in here. Despite all the yelling and screaming from some of our politicians [that] they don’t like the idea of having to show papers, people have long had to show proof of vaccination to immigrate here legally. And if we’re vaccinated thoroughly and some parts of the world are not, we’re going to be nervous about new strains [and] non-vaccination. We will absolutely demand proof of vaccination to get in here, and I’m certain other countries will too.

Hamblin: Does this not create, at least temporarily, two worlds where there are wealthy people from wealthy countries traveling to other wealthy countries that have vaccines—and then there are other countries that still don’t even have access that are going to be further marginalized in terms of global trade?

Caplan: I think you just described the pre-COVID state of affairs ... but I get the point. Will there be more isolation and more restriction because of vaccine inequity? Yes. Is that going to stop the demand for proof of vaccination for international travel? No. I think people are still going to want to be safe.

Now, is this going to endure long? No, I think we’ll have vaccine-rollout in most of the world probably within 18 months, maybe two years. But for that period of time, I think there will be the haves and the have-nots.

Higgins: Certainly, the U.S. is already a fortress for the many people who would like to visit or move there, so let’s talk about what happens within the U.S., and the other form of vaccine passport that you called vaccine certification or authentication.

Caplan: The U.S. has its remarkably strong love affair with freedom and liberty. Americans don’t like to be told what to do by their government about anything. They believe somehow in the naive view that they are free to do whatever they want, but they forget about things like traffic laws, seatbelt requirements, speeding restrictions ... You can’t just do what you want if it involves killing others.

And when [some Americans are] talking in the context of vaccines, they keep saying, “Well, you can’t make me do something that I don’t want to do.” But of course, if you pose a direct threat to others, you could be quarantined. You could be told that you can’t move around in a way that you might want to. And ultimately, we have many Supreme Court decisions that say you could be told to get vaccinated and be fined if you wouldn’t do it.

We’re not a society that says you can do whatever you wish in the name of freedom or liberty. But a lot of Americans worry that the government is going to make them get vaccinated, and that’s part of the resistance to the authentication. It’s not the paperwork, it’s, “You can’t make me get vaccinated.” Many of the same people who bridle, say conservatives in the U.S., at the notion of vaccine certification being demanded—I’ve seen it referred to as a Nazi regime asking for your papers as you travel about—are perfectly willing to ask for your papers if they think you’re not here legally.

And, oddly enough, it’s more likely their much-beloved private sector is going to start putting in requirements to show vaccine authentication. If you want to go to a sports event, Madison Square Garden has already said, “You can come in here two ways: You show us a negative COVID test that’s recent or you show us proof of vaccination.” They’re not the government. They’re just a private entity saying, “We’re going to make sure we draw customers by making sure they feel safe.” So you’re going to see more movement toward private-sector requirements, [and] the very same conservatives and libertarians who like the free market are going to be confronted with the reality of business and private entities saying, “Guess what? No shirt, no shoes, no shot, no service.”

Hamblin: Do you foresee this patchwork of private-sector requirements incentivizing vaccination enough that we don’t need government IDs or anything more centralized?

Caplan: No private entity can make you get vaccinated, and, outside of some sectors like the military and maybe health-care workers, the government isn’t ready to mandate vaccination. But if you don’t get vaccinated, then your employer could well say, “You can’t work here.” And it’s not discriminatory because there’s no racial, religious, or gender discrimination. It just means that, “to keep our workplace safe, we expect you, if you come in here, to be vaccinated.” And I think it’s easy right now for some conservatives and critics to say, “I don’t like this. They can’t make me.” I think they’re going to have to turn around and say to businesses that they can’t put those requirements in place. And I don’t think that will work. I think businesses will be free to do it.

But that said, I think the debate should move in this direction: First, if we’re going to have vaccine authentication, who’s issuing it if it’s not the government? Some of us have these cards from the CDC that we got when we got vaccinated. And they’re just little paper cards. They weren’t intended to be certificates or, if you will, domestic vaccine passports. [But] if I got one right now, I would take a picture of it, photocopy it, and then laminate it because I think it’s something you’re going to be able to show as proof. But that’s controversial. Maybe we should have apps certified by private businesses that you pay, and they talk to your doctor and make sure that you really did get the shot, along with the date and kind of shot you got. But that’s going to be a fight over whether private businesses can impose requirements on people to enter public places like a cruise ship or a sporting event. But again, I absolutely think they can.

Hamblin: This has become partisan pretty quickly. And we don’t want to do anything that dissuades people who otherwise would have gotten vaccinated into thinking it’s all part of a Democratic or a liberal plot to get information from you and upload your info to a system. And if there’s anyone in that group who actually wanted to get vaccinated for health reasons but is suddenly thinking it’s something their camp isn’t into ... How do we avoid stoking vaccine hesitancy because of the systems we implement?

Caplan: It’s important to point out that vaccine status is not a path to getting your medical record or personal information. (There’s an irony here, again, that many of the people who worry about that already have a credit card or a Facebook account where everything about them is tracked.) But your vaccine status doesn’t have to go anywhere with the rest of your data. So I don’t think that people on the edge about vaccination will be tipped over by having to show proof.

What I do think we could see is what we were talking about internationally. There may well be states in the U.S. that, for one reason or another, the businesses kind of agree they’re not going to require this to enter. I can imagine, say, the Sturgis Motorcycle Rally saying, “Anybody [who] wants to come here can come.” But returning to work if you went, [employers] may say, “Did you go to that thing? You better show me you were vaccinated.” You may see the differences we were talking about internationally, the haves and the have-nots, or the requiring [and] the not-requiring.

New York is already trying to set up a passport of the sort we’re talking about for domestic use. [But] maybe Arkansas or Alabama will be late to the game, [and so] we could see weird differences, like, say, an Arkansas business’s salesforce needing to get vaccinated to get into New York.

Hamblin: What is the Biden administration doing? You make the case sound so clear, and yet we’ve been hearing just this week that there’s not going to be a registry of vaccination. Why would they say that?

Caplan: Well, two reasons. One: The federal government has no authority about vaccination in the U.S. It’s a state issue. Many of us wake up thinking the federal government is this mighty power that controls everything and anything pertaining to our health. But even the CDC guidance on who ought to get vaccinated is guidance, and as soon as the vaccine went out to the states, they set up their own rules.

And I suspect the other honest reason is: They don’t want to get into it right now. They’re still trying to get people to put on a mask and hopefully get vaccinated. This is almost a more distant problem for them.

Hamblin: Right now, I’m in New York and I’m eligible, but I can’t actually get one because there’s not enough supply, so it would genuinely feel unfair to me if places required vaccination, because there’s no vaccine available to me. Do you think this could rapidly shift once we get to the point where there’s a Free COVID Vaccine sign outside of every CVS and the people walking past it are choosing not to go in?

Caplan: One thousand percent. I could even imagine a situation where places say, “If you want to come in, we happen to have a vaccination site here.” We did have a company, Krispy Kreme, say that if you get vaccinated, they’ll give you a donut a day for the rest of the year.

Hamblin: I like that positive incentivization. I was hoping that would lead to a cascade where all the corporations would suddenly be like, “Oh yeah, well, you can get free Nike shoes! And you get a free flight!”

Caplan: The Miami Heat basketball team has already offered a special section that you can sit in with good views if you’re vaccinated.

Hamblin: This is such an American capitalistic approach. It feels less politically divisive. There’s not actually a requirement, but you can get free stuff.

Caplan: I’m sure people in Ireland, Israel, China, etc., [are] all saying, “The Americans are insane. They don’t want their government to do things, but they’re perfectly happy to have giant corporations or little businesses put requirements on them.”

Higgins: It is quite stunning to me from my vantage point in Europe. And the other thing I keep wondering about, especially with this kind of conservative-led pushback: “We’re not going to give you all of our information.” It makes me think about [Deferred Action for Childhood Arrivals] and the younger Dreamers. Seven hundred thousand kids from undocumented families took that risk and gave their home addresses. They trusted the U.S. government enough to say, “OK, this is us. Here we are,” knowing that it could be all taken away, and then there’d be a database of them. There’s nothing like that for the vaccine. It’s not even possible, as you pointed out, that there would be some federal database.

Caplan: And here’s another thing that’s odd to much of the world: We also don’t have an integrated health system with records in it. If you ask a person in Israel [if they’re] worried about [their] privacy, they’re going to say, “What privacy? The health system is four HMOs. They know everything about me.”

Here, there are still people saying they’re not going to get health insurance, because they don’t want people to know about them. It’s a very different pluralistic approach. A good part of the world is very used to the government having all their health information.

Hamblin: But in the U.S., people are worried about that because they could actually be discriminated against in certain ways.

Caplan: Right. And so the irony of ironies again is: If you have a national health system like Britain or Israel, you’re not worried about being penalized. You don’t care what the government knows about you because you’re in the system.

Hamblin: It seems like vaccine passports are poking into all these preexisting concerns about privacy and inequities in access to care. This relatively small, seemingly straightforward measure is becoming politicized because it touches on so many of these things that are already raw.

Caplan: Let me end my thoughts about ironies here. People are saying, “I don’t want to have this obligation to show my vaccine status.” This is a country that, post-9/11, accepted gigantic screening and identity checks to travel on airplanes, to the point that you have to take off your shoes every time you march through an American airport.

And yet here we are having this weird discussion. “Well, the government can never ask me to do anything if I want to move about.” Go to the airport, buddy! See what’s being asked of you. You’ve got to go through a screening machine. They’ve got to have your documents. You better show your ID. Maybe it’s a tempest in a teapot as people get used to the idea of vaccination being around, but every time in America somebody says they want to know something about you, I do see pushback saying it’s a restriction of liberty.