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., Australia, and beyond. In 2023, the FDA listed 319 active drug shortages-up from just 61 in 2005. Some of the most critical shortages hit cancer drugs like carboplatin and cisplatin, leaving oncologists to choose between patients who both need the same treatment. No one wants to play God. But when supplies vanish, someone has to decide-and that decision can’t be left to chance.

Why Medication Rationing Is Happening Now

Drug shortages aren’t random. They’re the result of broken supply chains, manufacturing failures, and market consolidation. Three companies produce 80% of generic injectable drugs in the U.S., meaning if one plant shuts down, dozens of hospitals lose access. In 2023, 87% of community oncology clinics reported severe shortages of platinum-based chemotherapy drugs. Academic centers fared slightly better, but even they weren’t immune.

The problem isn’t just scarcity-it’s timing. A drug shortage can go from mild to critical in weeks. Hospitals don’t have months to prepare. They’re often caught off guard. That’s when bedside decisions happen. A nurse gives the last vial to the patient in Room 307 because they’re younger. A doctor delays treatment for someone with metastatic cancer because they think the other patient has a better shot. These aren’t policy decisions. They’re survival instincts-and they’re unfair.

What Ethical Rationing Actually Looks Like

Ethical rationing doesn’t mean picking patients based on gut feeling. It means using clear, agreed-upon rules so no one is left to guess who deserves care. The most respected framework comes from Daniels and Sabin’s “Accountability for Reasonableness.” It’s not about who lives or dies. It’s about how the decision is made.

There are four pillars:

• Publicity: Everyone-patients, staff, families-must know how decisions are made.
• Relevance: Criteria must be based on medical evidence, not bias. For example, prioritizing patients with curative intent over palliative care.
• Appeals: If a patient or family disagrees, there’s a way to challenge the decision.
• Enforcement: Someone has to make sure the rules are followed.

The American Society of Clinical Oncology (ASCO) added its own rules for cancer drugs: decisions must be made by a committee, not a single doctor. The committee should include pharmacists, nurses, social workers, ethicists, and even patient advocates. In hospitals that follow this model, allocation disparities drop by 32%. That’s not a small win-it’s life-changing.

How Criteria Are Applied in Real Cases

In Minnesota, when carboplatin ran out in 2023, they didn’t just say “give it to the sickest.” They built a tiered system:

1. Tier 1: Patients receiving treatment with curative intent, no equally effective alternative.
2. Tier 2: Patients with high recurrence risk and no other options.
3. Tier 3: Palliative care patients or those with alternatives.

This isn’t about age, income, or who shouts loudest. It’s about medical need and likelihood of benefit. One study showed that using these criteria increased survival rates by 14% in the highest priority group compared to ad-hoc rationing.

Other frameworks consider:

• How many years of life are saved?
• Will this drug give the patient meaningful time?
• Is the patient a healthcare worker? (Some frameworks prioritize frontline staff to keep the system running.)

But here’s the catch: not all hospitals use these tools. Only 36% have standing committees. In rural areas, that number drops to 32%. That means most patients are still being treated based on who’s on call that night.

The Human Cost of Poor Rationing

Behind every shortage is a story of moral injury.

One oncologist in Ohio told a JAMA survey: “I had to choose between two stage IV ovarian cancer patients for the last dose of carboplatin. I picked the one with the better lab results. I didn’t tell either one why.”

That’s not rare. Only 36% of patients are told they’re being rationed. Families assume the drug isn’t working. They don’t know it’s gone. Clinicians feel guilty. Burnout rates jump 27% when decisions are made alone. A 2022 Mayo Clinic study found hospitals with ethics committees had 41% lower burnout scores.

And then there’s the hidden inequity. A 2021 report found 78% of rationing protocols don’t include any measure to protect marginalized groups-Black, Indigenous, low-income, or rural patients. These are the same people who already face longer wait times and fewer specialists. When drugs are scarce, they’re often last in line.

What Works: Real Examples of Success

Not all hospitals are flying blind. At a large teaching hospital in Chicago, they created a Drug Shortage Response Team in 2022. It met every Monday. They tracked inventory in real time. They trained staff on communication scripts. They used a digital dashboard that flagged when a drug was down to 72 hours of supply.

When cisplatin ran low, they didn’t panic. They called the committee. They reviewed each case against the tiers. They notified patients in writing. They offered alternatives-like switching to carboplatin if safe-or clinical trials. They documented every decision. Within six months, clinician distress dropped by 52%.

Another hospital in Minnesota started a “conservation-first” policy. Instead of giving full doses, they used the lowest effective dose at the longest possible interval. For some patients, that meant cutting from weekly to every three weeks. It wasn’t ideal-but it stretched the supply by 40% and saved lives.

What’s Missing-and What’s Coming

The biggest gap? Standardization. Every hospital does it differently. One uses age. One uses survival probability. One uses who’s been waiting longest. That’s chaos.

The National Academy of Medicine is working on national standards, with draft criteria expected in early 2024. The FDA is launching an AI-powered early warning system to predict shortages before they happen-targeting a 30% reduction in duration by 2025.

But technology alone won’t fix ethics. What’s needed is training. A 2023 CDC toolkit recommends 8 hours of ethics education for all staff involved in rationing. Only 13% of hospitals currently offer it.

And patients? They need to be part of the conversation. ASCO now requires hospitals to document whether patients were informed. That’s a start. But transparency means more than a note in a chart. It means having a real conversation-about risk, hope, and limits.

What You Can Do

If you’re a patient or family member: ask. If you’re told a drug isn’t available, ask why. Ask if there’s a plan. Ask if others are getting it. You have a right to know.

If you’re a healthcare worker: push for a committee. Advocate for training. Document your decisions. Don’t make them alone.

If you’re a policymaker: fund the infrastructure. Require transparency. Hold manufacturers accountable. The 2012 law requiring early shortage notices is ignored by 32% of companies. That’s not a loophole-it’s a failure.

Rationing isn’t about choosing who lives. It’s about making sure no one dies because the system failed them.

Final Thoughts

Medication rationing isn’t going away. Drug shortages are rising, and they’re getting worse. But we don’t have to accept chaos. We can demand better systems. We can insist on transparency. We can train our teams. We can protect the most vulnerable. Ethical rationing isn’t about making hard choices-it’s about making them the right way. And that starts with having a plan before the crisis hits.