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. and beyond. In 2023, the FDA recorded 319 active drug shortages, with critical cancer drugs like carboplatin and cisplatin in such short supply that 70% of U.S. cancer centers had to make impossible choices. These aren’t temporary glitches-they’re systemic failures that force doctors, nurses, and pharmacists to decide who lives and who doesn’t, often with no clear guidance.

Why Rationing Happens

Drug shortages aren’t random. They’re the result of a fragile supply chain. Just three companies produce 80% of the generic injectable drugs used in hospitals. If one factory has a quality issue, a single drug can vanish from shelves for months. The 2012 FDA Safety and Innovation Act tried to fix this by requiring manufacturers to give six months’ notice before a shortage. But only 68% actually do. That leaves hospitals scrambling.

It’s not just about supply. Demand is rising. More people are getting cancer. More are living with chronic conditions that need expensive injectables. And when a drug like cisplatin-a cornerstone of chemotherapy for ovarian, lung, and testicular cancers-disappears, there’s no easy substitute. Oncologists don’t just adjust doses. They have to choose between patients.

How Ethical Rationing Works

Ethical rationing isn’t about picking patients randomly. It’s about using clear, fair rules so no one person’s bias decides who lives. The most respected framework comes from bioethicists Daniel and Sabin. It’s built on four pillars:

• Publicity: Everyone knows how decisions are made.
• Relevance: Choices are based on evidence-not gut feeling.
• Appeals: Patients or families can challenge a decision.
• Enforcement: Someone oversees that rules are followed.

ASCO, the American Society of Clinical Oncology, built on this with its 2023 guidance. They say rationing should happen at the institutional level-not at the bedside. That means a committee, not a single doctor, makes the call. This committee should include pharmacists, nurses, social workers, patient advocates, and ethicists. Not just doctors. Because this isn’t just a medical decision. It’s a moral one.

What Criteria Are Used?

There’s no single rulebook, but most frameworks agree on five key factors:

• Urgency of need: Who will die without it?
• Chance of benefit: Who’s most likely to survive or recover?
• Duration of benefit: Who will live longer because of it?
• Years of life saved: Who has more life ahead?
• Instrumental value: Should healthcare workers get priority so they can care for others?

For example, Minnesota’s 2023 guidelines for carboplatin and cisplatin say priority goes to patients with curative intent and no equally effective alternative. That means someone getting chemo to cure their cancer gets first dibs over someone getting it to slow down a terminal illness. It’s harsh, but it’s clear.

What Happens When There’s No Plan?

The scary truth? Most hospitals don’t have a formal system. A 2018 survey of 719 hospitals found only 36% had standing committees for drug shortages. And only 2.8% included ethicists. That means 64% of hospitals are relying on whoever is on call that night.

That’s bedside rationing. And it’s a disaster. A 2022 JAMA study found that when decisions are made by individual clinicians, allocation disparities go up by 32%. That means patients from minority groups, rural areas, or lower-income backgrounds are more likely to be left out. One oncologist in Texas told a reporter: “I had to choose between two stage IV ovarian cancer patients for limited carboplatin doses three times this month-with no institutional guidance.”

And it’s not just patients who suffer. Clinicians are drowning in moral distress. Nurses and doctors report nightmares, guilt, and burnout. A 2022 Mayo Clinic study found hospitals with formal ethics committees had 41% lower clinician distress scores. But without those committees, 51.8% of rationing decisions are made alone-by one doctor, under pressure, with no backup.

The Silent Victims: Patients Who Don’t Know

Here’s the darkest part: most patients don’t even know they’re being rationed. Only 36% are told when their treatment is delayed or reduced. That’s not just unethical-it’s a betrayal of trust. The Patient Advocate Foundation documented 127 formal complaints in 2021 from families who only found out after a loved one’s condition worsened.

Why hide it? Fear. Fear of panic. Fear of lawsuits. Fear of blame. But secrecy doesn’t protect anyone. It just makes people feel abandoned. Transparency doesn’t mean giving bad news-it means giving honest context. “We don’t have enough of this drug right now. Here’s how we’re deciding who gets it. Here’s how you can appeal.” That’s dignity. That’s care.

Who’s Left Behind?

Rural hospitals are hit hardest. Sixty-eight percent of them have no formal rationing protocol. Academic centers? Only 32% lack one. Why? Rural hospitals don’t have ethicists on staff. They don’t have the staff to form committees. They don’t have the time to wait 72 hours for a meeting while a patient’s tumor grows.

And it gets worse. A 2021 Hastings Center Report found that 78% of rationing protocols don’t include any equity metrics. That means race, income, zip code, and insurance status don’t even factor into the rules. In practice, that means the same systemic inequalities that exist in healthcare today get baked into who lives and who dies during a shortage.

What’s Being Done?

There’s hope. ASCO launched an online decision support tool in May 2023. The CDC updated its Crisis Standards of Care toolkit in March 2023. And the FDA’s new Drug Shortage Task Force is building an AI-powered early warning system to predict shortages before they happen-targeting a 30% reduction in duration by 2025.

But the biggest step forward? Certification. The American Society for Bioethics and Humanities is launching pilot programs in 15 states in early 2024 to certify hospital rationing committees. Think of it like a safety certification for hospitals: if you want to handle drug shortages, you have to meet minimum standards. Training. Transparency. Accountability.

What Can Be Done Now?

If you’re a patient or family member: ask. Ask your doctor: “Do you have a plan for drug shortages? Have I been told if my treatment might be affected?” If you’re a healthcare worker: push for a committee. Demand ethics training. Push for documentation in your EHR system. If you’re a policymaker: fund rural hospital support. Mandate transparency. Require manufacturers to report shortages on time.

There’s no perfect solution. But there’s a clear path forward: stop making these decisions alone. Stop hiding them. Stop letting profit and convenience dictate who gets medicine. Ethical rationing isn’t about choosing who lives. It’s about making sure no one is chosen arbitrarily.