In Practice

Age discrimination in critical care triage in South Africa: The law and the allocation of scarce health resources in the COVID-19 pandemic

N Erasmus


No one may be refused emergency medical treatment in South Africa (SA). Yet score-based categorical exclusions used in critical care triage guidelines disproportionately discriminate against older adults, the cognitively and physically impaired, and the disabled. Adults over the age of 60, who make up 9.1% of the SA population, are most likely to present with disabilities and comorbidities at triage. Score-based models, drawn from international precedents, deny these patients admission to an ICU when resources are constrained, such as during influenza and COVID-19 outbreaks. The Critical Care Society of Southern Africa and the South African Medical Association adopted the Clinical Frailty Scale, which progressively withholds admission to ICUs based on age, frailty and comorbidities in a manner that potentially contravenes constitutional and equality prohibitions against unfair discrimination. The legal implications for healthcare providers are extensive, ranging from personal liability to hate speech and crimes against humanity. COVID-19 guidelines and score-based triage protocols must be revised urgently to eliminate unlawful discrimination against legally protected categories of patients in SA, including the disabled and the elderly. That will ensure legal certainty for health practitioners, and secure the full protections of the law to which the health-vulnerable and those of advanced age are constitutionally entitled.

Author's affiliations

N Erasmus, Honorary Lecturer in Health Law, Unit for Undergraduate Medical Education, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa

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Triage; ICU; Intensive care unit; Critical care; Frailty; Equality law; Hate speech; Crimes against humanity; Intimidation; South African Constitution; Emergency treatment; COVID-19; Pandemic; Scarce resources; Unfair discrimination; Old age; Disability

Cite this article

South African Medical Journal 2020;110(12):1172-1175. DOI:10.7196/SAMJ.2020.v110i12.15344

Article History

Date submitted: 2020-11-05
Date published: 2020-11-05

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