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 Australia. In 2023, the FDA tracked 319 active drug shortages, with cancer drugs like carboplatin and cisplatin hitting critical levels. Oncology centers reported that 70% of patients faced delays or denied treatment because of these shortages. When there’s not enough to go around, doctors don’t just guess who gets the medicine. They follow ethical frameworks-structured, sometimes painful, rules designed to make the impossible just a little less unfair.

Why Rationing Happens

Drug shortages aren’t random. They’re the result of broken supply chains, manufacturing failures, and a market that rewards cheap generics over reliable production. Just three companies make 80% of the generic injectable drugs hospitals rely on. When one plant shuts down-because of contamination, labor issues, or profit decisions-it sends shockwaves through the system. Sterile injectables, especially cancer drugs, make up 43% of all shortages. And when these drugs disappear, there’s often no easy substitute.

In 2023, a single shortage of carboplatin forced oncologists to choose between two stage IV ovarian cancer patients. One had just finished chemo and was due for maintenance. The other was newly diagnosed with aggressive disease. Both needed the same drug. One would get it. The other wouldn’t. No one wants to be the one making that call. But someone has to.

The Ethical Frameworks That Guide Decisions

Hospitals aren’t supposed to make these calls at the bedside. That’s how moral distress, burnout, and inequality creep in. Instead, leading health organizations recommend committee-based systems built on four core principles from the Daniels and Sabin framework:

• Publicity: The rules must be clear and shared with staff and patients.
• Relevance: Decisions must be based on evidence-not personal bias or hospital politics.
• Appeals: There must be a way to challenge a decision if you think it’s wrong.
• Enforcement: Someone has to make sure the rules are followed.

The American Society of Clinical Oncology (ASCO) added cancer-specific criteria: priority goes to patients with curative intent, no equally effective alternative, and the highest chance of survival. A patient with a 60% chance of living five more years gets preference over someone with a 15% chance, even if the second patient is younger. It’s not about age. It’s about benefit.

Other frameworks consider: how urgent the need is, how long the benefit will last, and whether saving a life means saving more years overall. Some even include “instrumental value”-giving priority to healthcare workers who keep the system running. But these are exceptions, not the rule.

What Happens When There’s No System

In 2022, a survey of 247 pharmacy managers found that 51.8% of rationing decisions were made by individual doctors or nurses-no committee, no guidelines, no transparency. That’s bedside rationing. And it’s dangerous.

Clinicians who make these calls alone report 27% higher burnout rates. Patients are rarely told what’s happening. Only 36% of patients affected by rationing were informed, according to JAMA. That means two out of three people were denied treatment without knowing why. Some were told the drug was “out of stock.” Others were never told at all.

Hospitals without formal committees also see more inequality. One department hoards drugs. Another runs out. Wealthier patients get better access. Rural hospitals? 68% have no formal protocol at all. Academic centers? Only 32% lack one. The gap isn’t just logistical-it’s ethical.

How the Best Hospitals Do It

The hospitals that handle this well don’t wait for a crisis. They prepare. The Minnesota Department of Health released a detailed plan for carboplatin and cisplatin rationing in April 2023. It included:

• Priority tiers based on treatment goals (curative vs. palliative)
• Dose optimization: using the lowest effective dose for the longest possible interval
• Strict documentation in electronic health records: every rationing decision must be logged with justification and communication notes

They also built multidisciplinary committees: pharmacists, nurses, doctors, social workers, patient advocates, and ethicists. The committee meets within 24 hours of a shortage declaration. They review cases, apply the rules, and document everything. These hospitals saw 41% lower clinician distress scores and 32% fewer disparities in who received treatment.

But here’s the catch: only 36% of U.S. hospitals had standing shortage committees in 2018. That number hasn’t jumped much. And only 2.8% of those committees included an ethicist. Most still operate in the dark.

The Real Problem: Inconsistency

The biggest complaint from pharmacists? Inconsistent application. One hospital gives priority to patients with the best prognosis. Another gives it to those who’ve been waiting longest. Another uses a lottery. No national standard exists. No federal mandate. No uniform training.

A 2021 Hastings Center Report found that 78% of rationing protocols ignore equity. They don’t account for race, income, geography, or language barriers. A patient in rural Alabama might get the same drug as one in downtown Chicago-but only if they’re lucky. The system doesn’t fix inequality. It amplifies it.

And the manufacturers? They’re not helping. The 2012 FDA law required drugmakers to report shortages six months in advance. But only 68% comply. Some wait until the last minute. Others don’t report at all.

What’s Being Done Now

Change is slow, but it’s happening. In May 2023, ASCO launched an online decision support tool to help oncologists apply ethical criteria in real time. In January 2024, pilot certification programs for hospital rationing committees began in 15 states. The FDA’s new AI-driven early warning system, expected to launch in 2025, aims to predict shortages before they happen-cutting duration by 30%.

The National Academy of Medicine is developing standardized ethical metrics for allocation. Draft criteria are due in mid-2024. For the first time, we might have a common language for fairness: what counts as “urgent,” what counts as “benefit,” who gets to decide, and how we measure success.

What Patients and Families Can Do

You can’t control the supply chain. But you can ask questions.

• Ask: “Is this drug in short supply? If so, what’s the plan if it runs out?”
• Ask: “Is there a committee that makes these decisions? Can I see the criteria?”
• Ask: “Will I be told if I’m not getting the drug? How will I be informed?”

If you’re in a community clinic or rural hospital, push for a formal process. Demand transparency. Share your story. The more people speak up, the harder it is for systems to ignore the problem.

The Bottom Line

Rationing isn’t about choosing who lives or dies. It’s about choosing how to be fair when there’s not enough to go around. The goal isn’t perfection-it’s accountability. The goal isn’t to avoid hard choices-it’s to make them together, with clear rules, and with honesty.

Right now, too many hospitals are flying blind. Too many patients are being left in the dark. Too many doctors are carrying the weight alone. The solution isn’t more drugs-it’s better systems. And those systems can be built. They just need the will to do it.