Rationing Medications: How Ethical Decisions Are Made During Drug Shortages

When there isn’t enough medicine to go around

Imagine you’re an oncologist. Two patients need carboplatin - the same stage of cancer, similar age, same prognosis. But there’s only one dose left. Who gets it? This isn’t science fiction. It’s happening right now in hospitals across the U.S. As drug shortages grow more frequent and severe, doctors, pharmacists, and nurses are being forced to make choices no one should have to make. And without clear rules, those choices become arbitrary, unfair, and deeply traumatic.

Why are drug shortages getting worse?

It’s not just bad luck. The problem has been building for years. In 2005, there were 61 drug shortages reported in the U.S. By 2023, that number had jumped to 319, according to the FDA. Most of these are critical injectable drugs - cancer treatments, antibiotics, anesthetics - things you can’t replace easily. A single manufacturer often controls 80% of the supply for a generic drug. If one factory has a quality issue, or a raw material shipment gets delayed, the whole country feels it.

Manufacturers aren’t always required to warn hospitals in advance. Even though the 2012 FDA Safety and Innovation Act asked them to notify regulators six months before a shortage, only 68% follow through. Meanwhile, hospitals are spending an average of $218,000 a year just managing these disruptions - buying expensive alternatives, rerouting supply chains, and dealing with the chaos.

What does ethical rationing actually look like?

Ethical rationing isn’t about picking who lives or dies. It’s about making sure that when you can’t give everyone what they need, you do it fairly. The most respected framework comes from bioethicists Daniel and Sabin, called “Accountability for Reasonableness.” It has four rules:

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

These aren’t just ideas. The American Society of Clinical Oncology (ASCO) used them to create real guidelines for oncology drug shortages. Their 2023 guidance says allocation decisions should happen at the committee level - not at the bedside. A team of pharmacists, nurses, doctors, social workers, ethicists, and even patient advocates should meet to decide who gets what, based on clear criteria like:

• Urgency of need
• Chance of survival
• How many years of life the treatment might add
• Whether there’s a safe alternative

For example, Minnesota’s 2023 protocol for carboplatin and cisplatin says priority goes to patients getting treatment with curative intent - not just symptom relief - and only if no other drug works as well.

Why do most hospitals still get it wrong?

Despite the clear guidelines, most hospitals aren’t following them. A 2018 survey of 719 hospital pharmacists found only 36% had a standing committee to handle shortages. Of those, just 13% included doctors, and only 2.8% had an ethicist on the team. That means most decisions are still made by one doctor, in the middle of a crisis, with no backup.

This is called bedside rationing. And it’s dangerous. A 2022 JAMA Internal Medicine study showed that when decisions are made at the bedside, allocation disparities - meaning some groups get treated more than others - go up by 32%. It also leads to more burnout. Nurses and doctors who make these calls alone report 27% higher burnout rates. One oncologist 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.”

Who gets left out?

Even when committees exist, they often ignore the people who need help the most. A 2021 Hastings Center Report found that 78% of rationing protocols don’t include any specific measures to protect marginalized communities - people of color, low-income patients, rural residents, or those without strong advocates. In rural hospitals, 68% have no formal rationing plan at all. Meanwhile, academic medical centers are better equipped, meaning the same drug might be available in Chicago but not in rural Kansas.

And patients? Only 36% are told they’re being rationed. That’s not just unethical - it’s a breach of trust. People have the right to know why they’re not getting a treatment. A 2021 Patient Advocate Foundation study recorded 127 formal complaints about undisclosed rationing. That’s not just a policy failure. It’s a moral failure.

What’s being done to fix it?

Change is slow, but it’s happening. In January 2024, pilot programs launched in 15 states to certify hospital rationing committees. These programs train teams on the Daniels and Sabin framework, require regular ethics training, and mandate patient communication protocols. The American Society of Bioethics and Humanities is leading this effort, aiming for national standards by 2026.

The FDA is also stepping in. Their October 2023 Drug Shortage Task Force announced plans for an AI-powered early warning system that could predict shortages before they happen - targeting a 30% reduction in duration by 2025. Meanwhile, ASCO launched a free online decision tool in May 2023 to help oncologists apply their ethical guidelines in real time.

And hospitals that do it right see real results. A 2022 Mayo Clinic study found that institutions with ethics-involved committees had 41% lower clinician distress scores. Patients reported feeling more respected. And disparities in care dropped significantly.

What can hospitals do today?

You don’t need to wait for national standards to start doing better. Here’s what works:

1. Build a committee - even if it’s small. Include pharmacy, nursing, medicine, social work, and at least one ethicist.
2. Adopt a clear framework - use ASCO or Daniels and Sabin. Don’t invent your own.
3. Train your staff - 8 hours of ethics training and 4 hours of crisis communication can make all the difference.
4. Track everything - document every rationing decision in the electronic health record. Include why it was made and whether the patient was informed.
5. Communicate with patients - explain the shortage. Explain the criteria. Let them ask questions. Silence breeds fear.

What’s next?

The National Academy of Medicine is working on standardized ethical allocation metrics, with draft criteria expected in mid-2024. That could finally create a national baseline. But until then, hospitals have a choice: keep making decisions in the dark, or build systems that are fair, transparent, and humane.

The problem won’t go away. Drug shortages are projected to keep rising through 2027. The question isn’t whether we’ll ration - it’s whether we’ll ration with dignity.