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, over 300 drugs were in short supply across the U.S., including critical cancer treatments like carboplatin and cisplatin. Hospitals had to decide: which patient gets the next dose? Which one waits? And who gets to make that call?

Why Medication Rationing Happens

Drug shortages aren’t rare anymore. They’re a growing crisis. The FDA recorded 319 active shortages in October 2023 - up from just 61 in 2005. Most of these are sterile injectables, especially chemotherapy drugs, antibiotics, and anesthetics. Why? Manufacturing problems, supply chain breakdowns, and a market where just three companies produce 80% of generic injectables. When one plant shuts down, hundreds of hospitals feel it.

It’s not just about supply. Demand is rising too. More people are being diagnosed with cancer, more patients need antibiotics after surgery, and aging populations need more medications. When demand crashes into supply, something has to give. That’s when rationing kicks in - not because someone wants to, but because there’s no other choice.

What Ethical Rationing Actually Means

Rationing doesn’t mean picking patients randomly. It means using clear, fair rules so no one gets special treatment because they’re loud, rich, or connected. The goal is to avoid chaos. Without rules, doctors are left alone in a room with two dying patients and one vial of drug. That’s not medicine - that’s moral torture.

Experts agree on four key principles for ethical rationing:

• Transparency: Everyone - patients, families, staff - should know how decisions are made.
• Consistency: The same rules apply to everyone, no matter their race, income, or hospital wing.
• Accountability: Someone has to answer for the choices made.
• Appeals: If a patient or family thinks the decision was wrong, they can challenge it.

These aren’t just nice ideas. They come from the Accountability for Reasonableness framework developed by Daniel and Sabin in 2002. It’s the gold standard for healthcare rationing. And it’s being used now in real hospitals - when they have the systems in place.

Who Decides? The Committee Model

The best way to make these decisions isn’t at the bedside. It’s through a committee. A real team: a pharmacist, a nurse, a doctor, a social worker, a patient advocate, and an ethicist. Together, they review cases using evidence-based criteria.

For example, during the 2023 cisplatin shortage, the Minnesota Department of Health told hospitals to prioritize:

• Patients getting treatment meant to cure their cancer (not just slow it down)
• Those with no other effective drug options
• People who are most likely to survive if they get the drug now

Studies show this works. Hospitals using committees had 32% fewer unfair treatment gaps than those letting doctors decide alone. And clinicians were less burned out. One 2022 Mayo Clinic study found distress levels dropped by 41% when committees handled rationing.

But here’s the problem: only 36% of U.S. hospitals have these committees. And only 2.8% include an ethicist. Most are still making decisions on the fly - often by nurses or pharmacists who aren’t trained in ethics. That’s dangerous.

What Happens When There’s No Plan

Without a system, rationing becomes messy. Doctors report hoarding drugs. Oncology units lock up their supply. Patients get treated differently depending on which hospital they walk into. One patient might get their full dose. Another, with the same cancer stage, gets half - because the pharmacy ran out.

And patients? Most don’t even know they’re being rationed. A 2022 JAMA survey found only 36% of patients were told their treatment was limited. That’s not just unethical - it’s a betrayal of trust. Imagine being told your chemo is working, when really, you’re getting a reduced dose because someone else needed it more. And you never knew.

One oncologist on the ASCO forum wrote: “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 a rare story. It’s the norm in too many places.

What Criteria Are Used?

There’s no single rulebook, but most ethical frameworks use five key factors:

1. Urgency: Who needs it right now to survive?
2. Benefit likelihood: Who is most likely to respond?
3. Duration of benefit: Who will live longer with this drug?
4. Years of life saved: Prioritizing younger patients isn’t always fair, but it’s often used to maximize life-years.
5. Instrumental value: Should frontline workers get priority? Some frameworks say yes - if they’re needed to save others.

These aren’t guesses. They’re based on clinical data. For example, in cancer, doctors look at recurrence risk, survival rates, and how much time a drug adds to life. A 2023 ASCO guideline says: “If two patients have the same cancer type and stage, give the drug to the one with a higher chance of long-term survival.” Simple. Clear. Evidence-based.

Why Some Hospitals Fail

It’s not that hospitals don’t want to do the right thing. They’re overwhelmed. Setting up a committee takes time - at least 90 days, according to ASHP guidelines. It needs training, policies, legal review, and staff buy-in. Many hospitals don’t have the resources.

Rural hospitals are hit hardest. Sixty-eight percent have no formal rationing plan. Academic centers? Only 32% lack one. That means a patient in a small town might die because they can’t get the drug - while a patient in a big city gets it, not because they’re sicker, but because their hospital has a system.

And then there’s resistance. Fifty-seven percent of hospital leaders say doctors won’t give up control. “I know my patient best,” they say. But that’s exactly the problem. In a shortage, no one knows enough. That’s why teams matter.

What’s Being Done Now?

There’s progress. The FDA launched a Drug Shortage Task Force in October 2023, aiming to cut shortage duration by 30% by 2025 using AI to predict disruptions. ASCO released a new ethical tool in May 2023 to help doctors make fairer calls. The National Academy of Medicine is working on standardized criteria - draft rules expected in early 2024.

And something new: certification for hospital rationing committees. Starting January 2024, 15 states are piloting a program that trains and certifies teams to run ethical allocation. It’s the first time anyone’s building a real standard for this.

What You Can Do

If you or a loved one is facing cancer treatment, ask:

• Is there a shortage of my drug?
• Is there a committee deciding who gets it?
• Will I be told if my dose is reduced?
• Can I appeal if I think the decision is unfair?

Don’t assume you’ll be informed. Ask. Write it down. If your hospital doesn’t have a plan, push for one. Talk to the ethics department. Bring this article. Share it with your support group.

Medication rationing isn’t going away. But it doesn’t have to be cruel. With the right systems, we can make these decisions fairly - even when there’s not enough to go around.