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, carboplatin and cisplatin - two essential chemotherapy drugs - were in such short supply that 70% of U.S. cancer centers had to make impossible choices. One patient gets the dose today. Another waits. Maybe forever. No one wants to be the person deciding this. But someone has to.

Why We’re Talking About Rationing 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 injectable drugs - the kind you get in hospitals, often for cancer, infections, or heart conditions. The problem? A handful of manufacturers make most of these generics. Three companies control 80% of the market. If one factory has a quality issue, or a supply chain hiccup, the whole country feels it.

The FDA says 43% of shortages are sterile injectables. That means drugs you can’t just pick up at the pharmacy. These aren’t over-the-counter painkillers. These are treatments that keep people alive. And when they’re gone, hospitals don’t have time to wait.

What Rationing Actually Looks Like

Rationing doesn’t mean giving someone a smaller pill. It means deciding who gets the full dose, who gets a reduced one, and who gets nothing at all. It happens in real time, in exam rooms, in oncology units, in emergency departments.

Some hospitals let doctors decide on the spot. A nurse might say, “I’ll give it to the younger patient - they have more years ahead.” Another might pick the one with the best chance of survival. But that’s not fair. It’s not consistent. And it’s not ethical.

The real problem? When decisions are made at the bedside, they’re emotional, rushed, and often hidden. A 2022 study found that 51.8% of rationing decisions were made by individual clinicians - without any committee, without any guidelines. And here’s the kicker: only 36% of patients were even told they were being rationed.

The Ethical Frameworks That Try to Fix This

There are better ways. Experts have spent years building ethical frameworks to guide these decisions. One of the most respected is the Daniels and Sabin accountability model. It says four things must happen:

• Publicity: Everyone - patients, staff, families - must know how decisions are made.
• Relevance: Criteria must be based on evidence, not gut feeling. Who benefits most? Who has the greatest need?
• Appeals: If someone disagrees, there’s a way to challenge the decision.
• Enforcement: Someone has to make sure the rules are followed.

In oncology, the American Society of Clinical Oncology (ASCO) added specific rules: allocation should happen at the hospital level, not the bedside. A committee - with doctors, pharmacists, nurses, social workers, ethicists, and even a patient advocate - should meet and decide together.

They also use clinical criteria:

• Is this treatment curative? Or just palliative?
• Is there a viable alternative?
• What’s the expected survival benefit?
• How many years of life could this drug save?

The Minnesota Department of Health even created a tiered system for carboplatin and cisplatin:

• Tier 1: Curative intent, no alternative - gets the drug.
• Tier 2: Palliative care, but no other option - gets a reduced dose.
• Tier 3: Alternative therapy exists - doesn’t get it.

Why Most Hospitals Still Get It Wrong

You’d think hospitals would follow these guidelines. But they don’t.

A 2018 survey of 719 hospitals found only 36% had a standing committee for drug shortages. Of those, just 13.3% included physicians. Only 2.8% had an ethicist on the team. That’s not a committee. That’s a suggestion.

Rural hospitals are even worse. Sixty-eight percent have no formal rationing plan at all. Meanwhile, academic centers are better prepared - but still inconsistent.

And then there’s the resistance. Doctors hate being told what to do. Pharmacists are overwhelmed. Administrators don’t want to deal with the paperwork. So they wait. They hope the shortage ends. They make decisions quietly.

The result? Clinician burnout spikes. A 2022 study found that when rationing is done without structure, burnout rates go up by 27%. Moral distress - that feeling of being forced to do something you know is wrong - becomes common.

What Happens When You Don’t Have a Plan

Without a system, you get chaos.

Some departments hoard drugs. Oncology gets the last vial. ICU takes the rest. A patient in the ER dies because the drug was saved for someone else - and no one told them why.

Disparities grow. Wealthier patients get priority. Those with better insurance get access. Minority populations? They’re often left out. A 2021 report found 78% of rationing protocols don’t even track equity. They don’t ask: Who’s being left behind?

And patients? They’re kept in the dark. Only 36% are told they’re being rationed. That’s not just unethical - it’s a betrayal of trust.

One oncologist, Dr. Sarah Chen, told the ASCO 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 survival.

What’s Being Done to Fix It

There’s hope.

In 2023, ASCO launched a new online decision tool to help hospitals apply ethical criteria in real time. The CDC updated its Crisis Standards of Care toolkit. And in January 2024, pilot programs began in 15 states to certify hospital rationing committees - training them in ethics, communication, and fairness.

The FDA is also working on an AI-powered early warning system. It’s supposed to predict shortages before they happen - giving hospitals time to prepare.

But the real change needs to come from inside hospitals. Not from federal reports. Not from ethics papers. From action.

What Hospitals Can Do Today

You don’t need a perfect system. You just need a system.

Here’s what works:

1. Build a committee. Pharmacy, nursing, medicine, social work, ethics, and a patient rep. No exceptions.
2. Train your staff. Eight hours of ethics. Four hours of crisis communication. Make it mandatory.
3. Use clear criteria. Don’t say “best chance.” Say “curative intent with no alternative.”
4. Document everything. Why was this patient chosen? Was the family told? Record it.
5. Communicate with patients. Even if the news is bad, they deserve to know.

The American Medical Association has been calling for national standards since 2015. We’re still waiting.

What Patients and Families Should Know

If you or someone you love is in treatment, ask:

• Is there a shortage of this drug?
• How are decisions being made about who gets it?
• Is there a committee reviewing this?
• Can I see the criteria being used?
• Was I told about this? If not, why not?

You have a right to know. And if the answer is “no” or “we don’t have a plan,” speak up. Push for change.

It’s Not About Saving the Most Lives - It’s About Fairness

Ethical rationing isn’t about picking the “most deserving.” It’s about treating everyone with dignity, even when there’s not enough to go around.

It’s about saying: We won’t let chaos decide who lives or dies. We will make hard choices - together. And we will be honest about them.

The drugs are running out. But the ethics don’t have to.

What Comes Next

The National Academy of Medicine is working on standardized ethical metrics for rationing - expected in mid-2024. If they succeed, we might finally have national guidelines. But until then, the burden falls on hospitals, doctors, and patients.

This isn’t about politics. It’s about humanity. When the medicine runs out, we don’t get to choose who suffers. But we can choose how we respond. With fear. Or with fairness.

The choice is ours.