Rationing Medications: How Ethical Decisions Are Made During Drug Shortages

When a life-saving drug runs out, who gets it? This isn’t a scene from a dystopian novel-it’s happening in hospitals right now. In 2023, the U.S. Food and Drug Administration tracked 319 active drug shortages, with critical cancer drugs like carboplatin and cisplatin in such short supply that 70% of cancer centers had to change treatment plans. These aren’t just logistical problems. They’re ethical crises that force doctors, pharmacists, and nurses to make choices no one should have to make: which patient lives, and which one doesn’t.

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 biggest culprits? Generic injectable drugs-especially those used in cancer care, intensive care, and emergency medicine. These are often made by just three manufacturers who control 80% of the market. If one factory shuts down for quality issues, or if raw materials get delayed overseas, the whole system stumbles.

It’s not just about production. Hospitals hoard drugs out of fear, buying more than they need. Some departments stockpile carboplatin while others run out. This makes shortages worse, not better. And when a shortage hits, there’s no national system to say: "Here’s how we share what’s left." So someone has to decide-usually at the bedside.

What Ethical Rationing Actually Means

Rationing isn’t about denying care. It’s about distributing what’s available as fairly as possible. The goal is to stop random, emotional, or biased decisions. Without a clear system, the same drug might go to a wealthy patient with good insurance-or be withheld from someone with no voice.

Ethical rationing uses structured frameworks. One of the most respected is the accountability for reasonableness model from Daniels and Sabin. It says any decision must meet four rules:

• Publicity: Everyone knows how decisions are made.
• Relevance: Criteria must be based on evidence-not gut feelings.
• Appeals: Patients or families can challenge decisions.
• Enforcement: There’s a way to make sure rules are followed.

The American Society of Clinical Oncology (ASCO) added its own rules for cancer drugs: decisions shouldn’t be made by one doctor alone. They need a team. And patients need to know what’s happening.

How Decisions Are Made

There are five common criteria used to decide who gets the drug:

1. Urgency of need: Is this patient in immediate danger?
2. likelihood of benefit: Will the drug actually help them?
3. Duration of benefit: How long will the improvement last?
4. Saving the most years of life: Prioritizing younger patients with longer life expectancy.
5. Instrumental value: Giving priority to healthcare workers or first responders who can help others.

These aren’t arbitrary. They’re based on decades of bioethics research. For example, in a shortage of carboplatin, a patient with stage IV ovarian cancer who has no other treatment options and a 70% chance of survival gets higher priority than someone whose cancer is stable and can wait.

Some hospitals have gone even further. Minnesota’s health department released a detailed guide in April 2023. It says priority should go to patients with:

• Curative intent treatment
• No equally effective alternative
• Good organ function to handle the drug

This isn’t cold math. It’s trying to balance fairness with medical reality.

Who Makes the Call?

Too often, it’s the nurse or oncologist on shift-alone, tired, and under pressure. A 2022 study found that over half (51.8%) of rationing decisions were made at the bedside, without any committee. That’s dangerous. It leads to burnout, moral distress, and inconsistent care.

The best approach? A multidisciplinary committee. ASHP recommends a team with:

• Pharmacists (2)
• Nurses (2)
• Physicians (2)
• Social workers (1)
• Patient advocate (1)
• Medical ethicist (1)

Hospitals with these committees have 32% fewer disparities in who gets treatment. They also report 41% lower clinician burnout. But here’s the problem: only 36% of U.S. hospitals have a standing committee. And only 2.8% include an ethicist.

In rural hospitals, the gap is even wider. Sixty-eight percent have no formal rationing plan at all. Meanwhile, academic centers are better prepared. That means your chances of getting a fair shot depend on where you live.

The Hidden Cost: What’s Not Being Said

One of the most shocking facts? Only 36% of patients are told they’re being rationed. That’s not just unethical-it’s deeply harmful. Imagine being told your treatment is working, then finding out later that your doctor didn’t get the drug because there wasn’t enough to go around. Patients feel betrayed. Families file complaints. And clinicians feel guilty.

A 2021 study by the Patient Advocate Foundation documented 127 formal complaints about undisclosed rationing. One oncologist on ASCO’s online 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." The emotional toll is real. Clinicians who make these calls alone report 27% higher burnout rates. Many describe it as "moral injury"-a wound to their conscience.

What’s Being Done About It

There’s progress, but it’s slow. In May 2023, ASCO launched an online decision support tool to help teams apply ethical criteria in real time. The CDC updated its Crisis Standards of Care toolkit in March 2023. And in January 2024, pilot programs began in 15 states to certify hospital rationing committees-standardizing training and procedures.

The FDA is also working on an AI-driven early warning system to predict shortages before they happen, aiming to cut shortage duration by 30% by 2025. That’s important. Prevention is better than rationing.

But the biggest fix? Transparency. Clear rules. And making sure every patient knows what’s happening.

What Still Needs to Change

Despite all the frameworks, three major gaps remain:

• Equity isn’t built in: 78% of rationing protocols don’t measure how race, income, or zip code affect access. A Black patient in a rural clinic still has worse odds than a white patient in a big city hospital.
• Training is missing: Most doctors get zero education on rationing. How are they supposed to handle it?
• Documentation is poor: Only 22% of hospitals track rationing decisions in electronic records. If you don’t record it, it didn’t happen.

The American Medical Association has been calling for national standards since 2015. But without mandatory rules, hospitals keep doing it their own way.

What You Can Do

If you or a loved one is facing a drug shortage:

• Ask: "Is there a shortage of this drug?"
• Ask: "Is there a committee deciding who gets it?"
• Ask: "Have I been told why this decision was made?"
• Ask: "Can I appeal this?"

Don’t assume silence means everything’s fine. If you’re a healthcare worker, push for a committee. Demand training. Insist on documentation. These aren’t luxuries-they’re necessities.

Final Thought

Rationing medication isn’t about scarcity. It’s about choice. And every choice reflects our values. Do we believe everyone deserves a fair shot? Or do we let chance, money, and geography decide?

The systems we build today-whether they’re fair, transparent, and inclusive-will define what kind of healthcare we have tomorrow.