As case numbers rise and resources come under increasing pressure, Scottish Care’s chief executive warns against going down the “exceptionally dangerous road of determining that age is the main or significant determinant when we have to choose not to treat”.

Head of Scottish Care Dr Donald Macaskill highlights the potential for discrimination against older people throughout the pandemic, and warns against allowing age to become the sole criteria for allocating limited critical care resources.

He says a risk during the crisis - which some have suggested is almost “inevitable” - is that there will not be sufficient resources to enable every person who becomes severely ill with covid-19 to receive the same level of care they might expect in ordinary times.

“Phrases to describe this resource restriction such as ‘capacity challenge,’ ‘the management of patients’ and ‘clinical prioritisation’ have now come out from clinical contexts into ordinary parlance,” he states.  

“What is meant in effect is ‘rationing’ and the establishment of criteria to determine who gets what treatment and support.”

That clinicians, carers, politicians and all those involved in tackling the pandemic do their best with what they have for the people they care for is in no doubt, Dr Macaskill says as he acknowledges the potential impact on them:

“I know that the decisions they may have to make and take will be emotionally and psychologically traumatic for these professionals.

“Having said that we need now, I believe, as a wider society, to be both more aware of and to give assent to the criteria for such decision making, both to support the staff making those decisions and to protect the lives of some of our most vulnerable citizens and their families.

“Anyone can catch covid-19 as we have witnessed in the last few days in the United Kingdom with sad news of fatalities across the age spectrum.

“But what is also clear is that the virus does not treat everyone equally. We know from the mortality figures from across the world that older individuals, people with a supressed immune system and multiple co-morbidities are particularly likely to be chronically affected and to perhaps die.”

 

Dr Donald Macaskill highlights comments made by World Health Organisation director general Tedros Adhanom Ghebreyesus that older people are “valued and valuable members of our communities” who must be protected from the virus.

He also says underlying conditions and frailty are more significant in predicting a poor response to covid-19 than age alone.

Dr Macaskill continues: “Yet in some parts of the world one of the concerning issues has been the extent to which age has been automatically assumed to be a dispositive or exclusive indicator of mortality risk from covid-19.

“These models ignore the other realities which include that one’s gender and pre-existing conditions are key factors that correlate to the probability of dying from covid-19. Yet we are not saying that treatment should only be given to women.

“This mistaken assumption around age is both clinically wrong, ethically dangerous and potentially lethal…”

He argues “clear criteria” should be established at the outset of a pandemic emergency for clinicians to make judgements with the risk of resources becoming constrained.

“We have to prioritise…What matters is the basis on which you establish the triage or resource allocation or rationing system,” he says.

“They cannot be based on discriminatory characteristics or presumptions. In the current pandemic I would argue that it must surely be clinical factors alone which are used to determine who has the greatest need and who is likely to have the best clinical outcome.

“Age undeniably influences this process, but it can never be the sole criteria or even an overarching criteria. It may be the easiest one to utilise because we can determine age very quickly compared to the other influencers such as the clinical benefit of treatment, the frailty of the person and the extent to which they have co-morbidities.

“To base any treatment principle on an ethical model which considers chronological age as the ‘key’ significant indicator is quite simply to engage in the most obscene discrimination and to effectively devalue any human life beyond a certain age.”

He continues: “Will we make really hard decisions based on individual clinical prognosis or will we take the delusory easier but exceptionally dangerous road of determining that age is the main or significant determinant when we have to choose not to treat?

“Older people vulnerable to covid-19 in Scotland and across the United Kingdom today are grandparents and parents.

“They are workers, caregivers and volunteers. They are not disposable. They are the best of us, and we have a duty to be the best for them.”

 

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