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. In 2023, hospitals across the U.S. faced severe shortages of carboplatin and cisplatin-two critical chemotherapy drugs. Oncologists had to choose between patients with identical diagnoses. One might live. The other might not. No one wanted this job. But someone had to make the call.

Why Medication Rationing Is Happening Now

Drug shortages aren’t new, but they’ve gotten worse. In 2005, there were 61 reported shortages in the U.S. By 2023, that number jumped to 319. Most of these are sterile injectables-drugs given through IVs. Cancer drugs, antibiotics, and anesthetics top the list. Why? A few big manufacturers control most of the supply. When one factory has a quality issue, or a raw material runs out, the whole system stumbles. The FDA says 85% of generic injectables come from just three companies. That’s not competition. That’s vulnerability.

What Ethical Rationing Actually Means

Rationing isn’t about saying "no" to treatment. It’s about saying "who gets it first," when there’s not enough for everyone. Ethical rationing means using clear, fair rules instead of letting doctors decide on the spot. Without rules, decisions become random. A patient with a loud family might get priority. Someone without insurance might be left out. That’s not justice. It’s luck.

The most respected framework comes from bioethicists Daniel and Sabin. They say any fair system must have four things:

• Transparency-Everyone knows how decisions are made.
• Relevance-Decisions are based on medical facts, not personal bias.
• Appeals-Patients or families can challenge a decision.
• Enforcement-Someone checks that the rules are followed.

Who Decides? Committees Over Clinicians

In too many hospitals, a single doctor makes the call. That’s called bedside rationing. A 2022 study found over half of all rationing decisions happened this way. But here’s the problem: doctors are overwhelmed. They’re grieving. They’re burned out. Asking them to pick who lives or dies is unfair-and it leads to more trauma.

The better way? Multidisciplinary committees. These teams include pharmacists, nurses, social workers, patient advocates, and ethicists. They meet when a shortage hits. They review patient cases. They apply the same rules to everyone. Hospitals with these committees report 32% fewer disparities in who gets treatment. They also see lower burnout among staff.

But here’s the ugly truth: only 36% of U.S. hospitals have standing shortage committees. And only 2.8% include an ethicist. That means most decisions are made without the people who specialize in fairness.

How Do You Pick Who Gets the Drug?

There’s no perfect formula. But experts agree on key criteria:

• Urgency-Is this patient’s condition life-threatening right now?
• Chance of benefit-Will the drug actually help? Or is it just delaying the end?
• Duration of benefit-Will they live longer? Or just feel better for a few weeks?
• Years of life saved-Giving a drug to a 25-year-old might save decades. A 90-year-old might gain months.
• Instrumental value-Should frontline workers get priority? Some argue yes, because they save others.

In oncology, the American Society of Clinical Oncology (ASCO) added two more: recurrence risk and survival impact. If two patients need carboplatin, and one has a 70% chance of long-term remission while the other has a 15% chance, the higher chance gets priority.

What Happens When Rules Are Ignored

Without clear systems, bad things happen. Departments hoard drugs. Nurses hide vials in fridges. Patients aren’t told they’re being rationed. A 2022 survey found only 36% of patients knew their treatment was limited. That’s not informed consent. That’s deception.

One oncologist in Texas 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." That’s not medicine. That’s moral injury.

And it’s worse in rural areas. Sixty-eight percent of small hospitals have no formal rationing plan. Meanwhile, big academic centers have teams, protocols, and training. That’s not just unfair. It’s deadly.

What Works: Real Solutions in Practice

Minnesota’s Department of Health created a clear, step-by-step plan for carboplatin and cisplatin shortages in 2023. They ranked patients into tiers:

• Tier 1-Curative intent, no alternative, high chance of survival.
• Tier 2-Palliative intent, but significant symptom relief possible.
• Tier 3-No benefit expected, or alternatives exist.

They also said: use the lowest effective dose. Stretch the supply. Delay treatments if safe. Try other drugs. Don’t just say "no"-try everything else first.

Hospitals that followed this approach saw:

• 41% drop in clinician distress
• 89% fewer complaints about inconsistent care
• 72% of patients informed about rationing

The Big Gaps Still Left

Even the best systems miss something: equity. A 2021 report found 78% of rationing plans don’t track race, income, or zip code. That means people in poor neighborhoods or minority communities are more likely to be left out-because their outcomes are worse to begin with. Is that fair? Or are we just reinforcing existing gaps?

Also, training is weak. Only 13.3% of hospitals include physicians on their shortage committees. Pharmacists are doing the heavy lifting. But doctors hold the power. If they’re not at the table, change won’t stick.

What’s Coming Next

The FDA is building an AI-powered early warning system to predict shortages before they happen. That’s huge. If you know a drug will run out in 60 days, you can prepare. You can find alternatives. You can train your team.

The National Academy of Medicine is drafting standardized ethical metrics for 2024. And in January 2024, 15 states launched pilot programs to certify hospital rationing committees. That’s the first time anyone’s tried to make this a professional standard.

But the biggest fix? Transparency. Patients deserve to know. Families deserve to be heard. Clinicians deserve support. And the system deserves to be rebuilt-not just patched.

What You Can Do

If you or a loved one is facing a shortage:

• Ask: "Is there a rationing plan here?"
• Ask: "Who decided this? Can I see the criteria?"
• Ask: "Can I appeal this?"
• Ask: "Are there alternatives?"

If you’re a healthcare worker:

• Push for a committee. Even if it’s just three people.
• Use the CDC’s Crisis Standards of Care toolkit-it’s free and ready to use.
• Document every decision. Why? Because if it’s not written down, it didn’t happen.

Final Thought

Medication rationing isn’t about running out of pills. It’s about running out of moral clarity. We can’t fix the supply chain overnight. But we can fix how we respond. Fairness isn’t optional. It’s the foundation of medicine. When drugs are scarce, ethics become the most important medicine of all.