Older people should be denied treatment for the coronavirus if a younger, healthy person needs help, according to Prof Arthur Caplan, a prominent US medical ethicist. Age, he said, was a “valid criterion” to use when making the “terrible choice” of who should receive scarce resources during the pandemic. “To the extent to which data supports the risk of failure or the odds of success, age can justifiably be used to ration care if maximisation of lives saved is the overarching goal,” said Caplan – who is ethics adviser to the US government – in remarks in a debate published on Wednesday in the British Medical Journal. “The relevance of old age as a predictive factor of efficacy – combined with the powerful principle of healthcare affording equality of opportunity to enjoy a life – makes age an important factor in making the terrible choice of who will receive scarce resources in a pandemic,” the founding head of the division of medical ethics at New York University’s School of Medicine added. The row comes amid reports of an increase in the use of “do not resuscitate”, “do not treat” and “do not convey to hospital” orders for older people during the pandemic. Under the Equality Act, it is illegal to deny an older person access to healthcare on the basis of their age. But a “frailty” tool is being used across the NHS to determine which older people should be asked about limits to treatment, with age making up 50% of the frailty score. Dave Archard, emeritus professor at Queen’s University, Belfast, said an overburdened service is no excuse for discrimination that would result in a “cull” of older people. Using age as an indicator of clinical frailty and the likelihood of survival is, he said, crude and unreliable. “And if it is not a marker of something else then it is hard to see why age should be used as the determinative criterion,” he added. “It becomes exposed as wrongly discriminatory because it licences differential treatment based on ‘unwarranted animus or prejudice’ against old people. “To discriminate between patients in the provision of care on the grounds of age is to send a message about the value of old people. Such discrimination publicly expresses the view that older people are of lesser worth or importance than young people. It stigmatises them as second-class citizens. “It would be hard not to think – even if it was not intended – that a cull of elderly people was what was being aimed at.” Catherine Foot, director of evidence at the Centre for Ageing Better agreed. “Chronological age must never be the principle factor that determines a person’s right to care. Medically speaking, it is a poor proxy for a person’s capacity to respond well to intensive care and to recover. “And rationing care based on age speaks of a dangerous kneejerk ageism, where the older we get, the less value we have and the less important our lives are to save,” she said. Caplan said that while blanket exclusion based simply on age is wrong, he pointed out that it is already often used to decide who gets care when rationing is unavoidable. “There are two main principles which ground the use of age [in deciding who gets treatment],” he said. “The first is the notion of fair innings – that each existing person ought to enjoy an opportunity to live a life. [The second is if] the overarching principle for rationing is to maximise the number of lives saved.” The Department for Health and Social Care said: “Care and treatment for any individual should be based, as always, on an informed discussion between the patient and their treating clinician. Coronavirus does not change this in any way. The NHS has the capacity to provide ICU care for anyone who needs it.”