Rationing Medications: How Ethical Decisions Are Made During Drug Shortages

When a life-saving drug runs out, who gets it? This isn’t a hypothetical question-it’s happening right now in hospitals across the U.S. In 2023, the FDA tracked 319 active drug shortages, with cancer drugs like carboplatin and cisplatin hitting critical lows. At some hospitals, oncologists had to choose between two patients for a single dose. No one wants to make this call. But when supply vanishes, someone has to decide-and that decision can’t be left to chance.

Why Rationing Happens

Drug shortages aren’t new, but they’ve gotten worse. In 2005, there were 61 reported shortages. By 2011, that number jumped to 251. Today, it’s over 300. The main culprits? A handful of manufacturers produce 80% of generic injectable drugs, and when one factory shuts down or faces quality issues, the entire supply chain breaks. Sterile injectables-like those used in chemotherapy, ICU sedation, or emergency care-are especially vulnerable. One problem, like a contaminated vial, can shut down production for months.

It’s not just about scarcity. It’s about timing. A shortage can hit suddenly. A hospital might wake up to find its entire stock of cisplatin gone, with no delivery expected for weeks. That’s when bedside decisions start happening-and that’s when ethics become urgent.

The Ethical Problem

Doctors are trained to do what’s best for the patient in front of them. But when there’s not enough for everyone, that instinct creates chaos. One nurse might give a dose to the oldest patient. Another might prioritize the one with the best prognosis. A third might give it to the patient who screamed the loudest. That’s not care. That’s lottery.

Without a system, rationing becomes arbitrary. And arbitrary decisions breed injustice. Studies show that patients from marginalized communities-Black, Latino, low-income-are more likely to be left out when rationing happens without clear rules. Why? Because those patients often have less access to specialists, fewer advocates, and weaker hospital networks. In a crisis, they’re the first to lose out.

Meanwhile, clinicians suffer. A 2022 JAMA study found that nurses and doctors who made rationing decisions without support had a 27% higher chance of burnout. One oncologist on the ASCO forum said: “I’ve had to choose between two stage IV ovarian cancer patients for limited carboplatin doses three times this month with no institutional guidance.” That’s not just stressful. It’s traumatic.

How Ethical Rationing Works

There’s a better way. It’s called structured rationing-and it’s built on four core principles from the Daniels and Sabin framework:

1. Transparency: Everyone-patients, families, staff-must know how decisions are made.
2. Relevance: Criteria must be based on medical evidence, not gut feeling.
3. Appeals: If a patient or family disagrees, there’s a formal way to challenge the decision.
4. Enforcement: Someone must make sure the rules are followed.

These aren’t abstract ideas. They’re built into real protocols. For example, the Minnesota Department of Health’s 2023 guidelines for carboplatin and cisplatin say: “Priority goes to patients with curative intent and no equally effective alternative.” That’s specific. That’s fair. That’s not left to the bedside.

Effective systems use multidisciplinary committees. Not just doctors. Not just pharmacists. But also nurses, social workers, ethicists, and even patient advocates. These teams meet before a shortage hits, build a plan, and stick to it. Hospitals with these committees saw 32% fewer disparities in who got treatment, according to JAMA Internal Medicine.

What Criteria Are Used?

Ethical frameworks don’t guess. They use measurable criteria. The American Journal of Bioethics outlines five:

• Urgency of need: Is the patient in immediate danger without the drug?
• Chance of benefit: How likely is this drug to help? A 5% survival boost? Or 40%?
• Duration of benefit: Will this extend life by weeks-or years?
• Years of life saved: Younger patients often get priority because they have more life ahead.
• Instrumental value: Should a nurse or doctor who’s essential to the response get priority? Some frameworks say yes.

These aren’t ranked in order. They’re weighed together. A 70-year-old with a 60% chance of long-term survival might get priority over a 30-year-old with only a 10% chance. It’s not about age. It’s about outcomes.

ASCO’s 2023 guidance adds cancer-specific metrics: recurrence risk, stage of disease, and whether the patient has already tried other treatments. That’s smarter than generic rules. Cancer isn’t one disease. Rationing shouldn’t treat it like one.

Why Most Hospitals Still Fail

You’d think every hospital would have a plan by now. But here’s the truth: only 36% of U.S. hospitals had standing shortage committees in 2018. Even fewer had ethicists on them-just 2.8%. In rural hospitals, 68% had no formal protocol at all.

Why? Because setting up a committee takes time, money, and courage. It requires training. It means having hard conversations. It means admitting that your hospital might not be able to save everyone.

Many hospitals still rely on ad-hoc decisions. A pharmacy manager might call a few doctors. They huddle. They vote. No documentation. No patient notification. That’s not ethics. That’s damage control.

And it’s getting worse. The FDA says drug shortages will keep rising through 2027. The system isn’t broken. It’s unprepared.

What Patients Don’t Know

Here’s one of the darkest truths: only 36% of patients were told their treatment was being rationed. Not because hospitals are cruel. But because no one knew how to tell them.

Imagine being told your chemo is delayed. Then learning weeks later that they ran out-and you were one of the ones who didn’t get it. No explanation. No apology. That’s not just a medical failure. It’s a betrayal of trust.

ASCO’s 2023 update made patient communication a non-negotiable. Hospitals now must document whether the patient was informed, what was said, and if they had questions. Simple. Necessary. Long overdue.

What’s Being Done Now

There’s progress. In January 2024, pilot programs launched in 15 states to certify hospital rationing committees. These aren’t just forms. They’re training programs. Ethicists teach staff how to use the criteria. Nurses learn how to explain rationing to families. Pharmacists track every dose.

The FDA is building an AI-powered early warning system, aiming to predict shortages 30% faster by 2025. That’s huge. If a factory in Ohio shuts down, hospitals in California should know before they run out.

The National Academy of Medicine is drafting standardized metrics for allocation-expected in mid-2024. This could mean one national framework, not 5,000 different hospital policies.

What You Can Do

If you’re a patient: Ask your oncologist or pharmacist: “Do you have a plan if this drug runs out?” If they say no, ask for the ethics committee. Push for transparency.

If you’re a provider: Don’t wait for a crisis. Start building your committee now. Even if it’s just three people. Meet monthly. Practice scenarios. Document everything.

If you’re a policymaker: Fund training. Require ethics representation on all hospital shortage teams. Make patient communication mandatory. Stop treating this as a logistics problem. It’s a moral one.

Final Thought

Rationing isn’t about running out of drugs. It’s about running out of fairness. We’ve had decades to prepare. We haven’t. But we still can. The tools exist. The ethics are clear. What’s missing is the will to use them.

When the next shortage hits, let’s not ask: Who gets it? Let’s ask: How do we know we made the right choice? And how do we prove it to the person who didn’t get it?