Rationing Medications: How Ethical Decisions Are Made During Drug Shortages

When a life-saving drug runs out, who gets it? This isn’t science fiction. It’s happening right now in hospitals across the U.S. In 2023, there were 319 active drug shortages documented by the FDA - and many of them were critical cancer drugs like carboplatin and cisplatin. When these shortages hit, doctors don’t just wait. They make impossible choices. One patient gets the dose. Another doesn’t. And without clear rules, those decisions are often made in panic, not principle.

Why Rationing Happens - And Why It’s Necessary

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 control most of the generic injectable market - just three companies make 80% of these drugs. If one factory has a quality issue, production halts. No backups. No alternatives. And when that happens, hospitals run out fast.

Oncology drugs are hit hardest. Between March and August 2023, 70% of U.S. cancer centers reported severe shortages of carboplatin and cisplatin. These aren’t optional meds. They’re the backbone of treatment for ovarian, lung, and testicular cancers. Without them, survival rates drop. So when supply can’t meet demand, someone has to decide who gets treated. That’s rationing. And it’s not about being cruel. It’s about being fair when there’s no other option.

The Ethical Frameworks That Guide These Decisions

Good rationing isn’t random. It’s built on ethics. The most respected model comes from Daniel and Sabin - called “accountability for reasonableness.” It has four rules:

• Publicity: Everyone must know how decisions are made.
• Relevance: Criteria must be based on medical evidence, not personal bias.
• Appeals: Patients or families can challenge a decision.
• Enforcement: There must be oversight to make sure rules are followed.

The American Society of Clinical Oncology (ASCO) added its own rules for cancer care:

• Decisions should be made by a team - not one doctor at the bedside.
• The team must include pharmacists, nurses, ethicists, and patient advocates.
• Patient communication is mandatory. No one should be left in the dark.

And here’s what they use to rank patients:

• Urgency: Who needs it now to survive?
• Likelihood of benefit: Who’s most likely to respond?
• Duration of benefit: Who will live longer with the treatment?
• Years of life saved: Prioritizing younger patients when outcomes are equal.
• Instrumental value: Should healthcare workers get priority to keep the system running?

These aren’t guesses. They’re based on data from clinical trials, survival rates, and outcomes research.

What’s Actually Happening in Hospitals - The Gap Between Policy and Practice

Here’s the problem: most hospitals don’t follow these rules.

A 2022 study in JAMA Internal Medicine found that 51.8% of rationing decisions were made by individual doctors or nurses - no committee, no transparency, no appeal process. That’s bedside rationing. And it’s dangerous. Clinicians who make these calls alone report 27% higher burnout rates. They’re traumatized. One oncologist told a forum: “I’ve had to choose between two stage IV ovarian cancer patients for limited carboplatin doses three times this month - with no institutional guidance.”

Even worse, only 36% of patients are told they’re being rationed. That’s not just unethical - it’s a breach of trust. Families deserve to know why treatment was delayed or changed. The Patient Advocate Foundation recorded 127 formal complaints in 2021 about undisclosed rationing.

And then there’s the “hoarding” problem. Departments sometimes stash drugs for their own patients, leaving others with nothing. A 2018 survey found 68% of pharmacists saw this happen. It’s human nature - protect your own. But it makes the shortage worse for everyone else.

Why Some Hospitals Get It Right

The hospitals that handle shortages well have one thing in common: they have standing ethics committees. These aren’t ad-hoc groups formed when a crisis hits. They’re permanent teams with clear roles:

• 2 pharmacists
• 2 nurses
• 2 physicians
• 1 social worker
• 1 patient advocate
• 1 ethicist

These teams meet before a shortage even happens. They’ve pre-approved criteria. They’ve trained staff. They’ve practiced scenarios. When carboplatin runs out, they don’t scramble. They act.

Hospitals with these committees report 32% fewer disparities in who gets treated. They also have 41% lower clinician distress scores. That’s not magic. It’s structure.

Minnesota’s 2023 guidance for carboplatin and cisplatin shows how specific these rules can be:

• Tier 1: Curative intent, no alternative drug available.
• Tier 2: Palliative intent, but treatment significantly improves quality of life.
• Tier 3: Experimental or low-benefit use - deferred.

They even recommend lowering doses and stretching intervals - using the least amount needed to still be effective. That’s smart conservation, not just rationing.

The Big Failures - And Who Gets Left Behind

The biggest flaw in current systems? They ignore equity.

A 2021 report from the Hastings Center found that 78% of rationing protocols don’t include any metrics for racial, economic, or geographic fairness. That means patients in rural areas, low-income neighborhoods, or minority communities are more likely to be denied care - not because they’re less sick, but because their hospital doesn’t have the resources to build a fair system.

Rural hospitals are hit hardest. 68% have no formal rationing protocol. Academic centers? Only 32% lack one. So if you live in a small town, your chance of getting life-saving treatment during a shortage is already stacked against you.

And let’s not forget: these shortages aren’t random. They’re tied to how drugs are made. Most generic injectables are produced overseas. Supply chains are fragile. Regulations are weak. And manufacturers aren’t punished for failing to report shortages early. Only 68% meet the 6-month notification requirement.

What’s Being Done - And What’s Coming Next

Change is slow, but it’s coming.

In May 2023, ASCO launched an online decision support tool to help hospitals apply ethical criteria in real time. In April 2023, Minnesota became the first state to publish binding allocation guidelines for two key drugs. The FDA’s new Drug Shortage Task Force is building an AI-powered early warning system - aiming to cut shortage duration by 30% by 2025.

The National Academy of Medicine is working on standardized ethical metrics - draft rules expected in early 2024. And the American Society for Bioethics and Humanities is launching pilot certification programs for hospital rationing committees in 15 states as of January 2024.

These aren’t just paperwork. They’re the first steps toward making rationing predictable, fair, and humane.

What You Can Do - Even If You’re Not a Doctor

You don’t need to be in a hospital to care about this.

If you or a loved one is on a drug that’s been on the FDA’s shortage list, ask your provider:

• Is there a rationing protocol here?
• Who makes the decisions?
• How will I be informed if my treatment changes?
• Are alternatives available?

If the answer is “no” or “we don’t know,” push for answers. Contact your state health department. Share your story. Demand transparency.

Hospitals won’t fix this unless they’re held accountable. And patients - even those not yet affected - have the power to demand better.

Final Thought: Fairness Isn’t Optional

Rationing isn’t about choosing who lives or dies. It’s about choosing how we treat each other when resources are scarce. If we let fear, bias, or convenience drive these decisions, we break the promise of medicine: that care is based on need, not luck, zip code, or who spoke loudest.

The tools exist. The ethics are clear. The data is there. What’s missing is the will to use them - consistently, fairly, and without delay.