When a life-saving drug runs out, who gets it? This isn’t a dystopian fiction scenario-it’s happening right now in hospitals across the U.S. and the U.K. In 2023, the FDA tracked 319 active drug shortages, with critical cancer drugs like carboplatin and cisplatin in such short supply that 70% of cancer centers had to delay treatments. These aren’t minor inconveniences. These are decisions that decide who lives and who doesn’t. And without clear rules, those decisions are being made on the fly-by exhausted doctors, overburdened nurses, and pharmacists who shouldn’t have to play god.
Why rationing happens: the crisis behind the shortage
Drug shortages aren’t random accidents. They’re the result of broken supply chains and concentrated manufacturing. Just three companies produce 80% of generic injectable drugs in the U.S. When one factory shuts down-due to quality issues, raw material shortages, or financial strain-it doesn’t just delay a shipment. It creates a domino effect. In 2023, a single plant closure led to a nationwide shortage of cisplatin, a drug used to treat ovarian, lung, and testicular cancers. Hospitals scrambled. Some patients got half-doses. Others waited weeks. Some didn’t get it at all. The problem isn’t just supply. It’s demand. Cancer treatments, antibiotics for sepsis, and anesthetics for surgery are non-negotiable. You can’t substitute them with a pill or a placebo. When supply drops below 80% of normal levels, rationing becomes unavoidable. And without a plan, hospitals fall back on the worst possible method: bedside decisions.Bedside rationing: the dangerous default
Too often, the person deciding who gets the last vial of carboplatin is the oncologist treating the patient. That’s not ethics. That’s moral overload. A 2022 study in JAMA Internal Medicine found that over half (51.8%) of rationing decisions were made by individual clinicians without any committee, policy, or guidance. One oncologist in Texas told a reporter: “I had to choose between two stage IV ovarian cancer patients last month. One had a better prognosis. The other had two kids. I picked the one with the better odds. I didn’t sleep for three nights.” This approach doesn’t just hurt patients-it destroys clinicians. The same study found that hospitals relying on bedside rationing had 27% higher rates of clinician burnout. Nurses and doctors report nightmares, guilt, and panic attacks. They’re not trained to be triage officers. They’re trained to heal. When the system fails them, they pay the emotional price.The ethical framework: what works
There are better ways. The most respected model comes from bioethicists Daniel and Sabin, who developed the “accountability for reasonableness” framework in 2002. It’s simple, but powerful. Four rules:- Publicity: Everyone must know how decisions are made. No secret lists.
- Relevance: Criteria must be based on evidence-not favoritism, not seniority, not who shouts loudest.
- Appeals: If a patient or family disagrees, there’s a clear path to challenge the decision.
- Enforcement: Someone must make sure the rules are followed. No exceptions.
How rationing criteria actually work
It’s not just “who’s sickest.” Ethical frameworks use specific, measurable criteria:- Urgency of need: Is this patient about to die without the drug today?
- Likelihood of benefit: Will this drug actually help? For example, cisplatin works best in early-stage cancer. If a patient’s cancer has spread too far, the benefit is minimal.
- Duration of benefit: Will this treatment extend life for months-or just days?
- Years of life saved: A 30-year-old with treatable cancer may get priority over an 80-year-old with multiple comorbidities, not because age matters, but because the potential life-years saved are greater.
- Instrumental value: In rare cases, healthcare workers or first responders may be prioritized if their survival means more lives are saved overall.
Where systems fail: the hidden inequities
Here’s the ugly truth: rationing doesn’t treat everyone equally. A 2021 report from the Hastings Center found that 78% of hospital rationing protocols don’t include any equity measures for marginalized groups. That means low-income patients, racial minorities, and rural communities are more likely to lose out-not because they’re less deserving, but because they’re less visible. Rural hospitals? Only 32% have formal rationing protocols. Academic centers? 68%. Why? Because academic hospitals have ethicists on staff. They have dedicated pharmacy teams. They have time and money. Community clinics? They’re lucky if they have one pharmacist working 60 hours a week. When a shortage hits, they don’t have a committee. They have a voicemail. And patients? Only 36% are told they’re being rationed. That’s not informed consent. That’s silence.
What’s being done: progress and gaps
There are signs of change. In May 2023, ASCO launched an online decision support tool that helps clinicians navigate shortages using real-time data. The FDA is building an AI-driven early warning system to predict shortages before they happen-targeting a 30% reduction in duration by 2025. And in January 2024, pilot certification programs for hospital ethics committees began in 15 states. But adoption is still slow. Only 36% of U.S. hospitals have standing shortage committees. Only 13.3% include physicians. And just 2.8% include ethicists. That’s not a system. That’s a patchwork. The American Medical Association has been calling for national standards since 2015. So far, they’ve been ignored. Without federal guidance, hospitals are left to invent their own rules. Some are thoughtful. Some are arbitrary. And patients pay the price.What hospitals need to do now
If you’re a hospital administrator, here’s what you need to do-starting today:- Form a shortage response committee with pharmacy, nursing, medicine, social work, patient advocacy, and ethics representation.
- Adopt the Daniels and Sabin framework. Make it public. Post it on your intranet.
- Train staff. Eight hours of ethics training. Four hours of crisis communication.
- Track every rationing decision in your electronic health record. Include fields for justification and patient communication.
- Always tell patients. Not “We’re out of stock.” But “We have a limited supply. Here’s how we’re deciding who gets it.”
The future: can we fix this?
The root causes-manufacturing consolidation, fragile supply chains, lack of regulatory enforcement-won’t be solved overnight. But the ethical failures? Those can be fixed now. We don’t need more drugs. We need better rules. The goal isn’t to make rationing easy. It’s to make it fair. To make it transparent. To make it human.Because when you’re choosing who lives and who doesn’t, you’re not managing a shortage. You’re managing morality.
Is it legal to ration medications in hospitals?
Yes, rationing is legal when done under a formal, transparent, and ethically reviewed protocol. There’s no federal law banning it, but the American Medical Association and other bodies require that rationing must follow ethical guidelines-such as fairness, consistency, and patient communication. Arbitrary or discriminatory rationing (e.g., based on race, income, or insurance) is illegal under civil rights and healthcare equity laws.
Why don’t hospitals just order more drugs?
Many drugs, especially sterile injectables, are made by only one or two manufacturers. If those companies can’t produce enough-or if a factory shuts down due to quality violations-there’s no backup. Unlike antibiotics or pills, injectables require complex, sterile production. You can’t just switch suppliers overnight. Even if hospitals order extra, manufacturers often can’t fulfill the demand.
Can patients be prioritized based on how much they can pay?
No. Prioritizing patients based on ability to pay is unethical and illegal in the U.S. and U.K. Ethical rationing frameworks explicitly forbid financial status as a criterion. Decisions must be based on clinical need, likelihood of benefit, and fairness-not wealth. Hospitals that use payment status as a factor risk lawsuits, loss of accreditation, and criminal liability.
What happens if a hospital doesn’t have a rationing plan?
Without a plan, rationing becomes chaotic and inconsistent. Clinicians make decisions alone, leading to higher burnout, unequal treatment, and potential legal exposure. In 2022, the CDC warned that hospitals without formal protocols are more likely to violate ethical standards and expose patients to harm. While there’s no federal penalty, Joint Commission surveyors may cite facilities for failing to ensure safe, equitable care.
Are there alternatives to rationing?
Yes, but only if acted on early. The best approach is a three-step strategy: first, conserve doses by using the lowest effective amount and extending intervals. Second, substitute with approved alternatives-like using carboplatin instead of cisplatin when possible. Third, only then resort to formal allocation. Most hospitals skip the first two steps, jumping straight to rationing because they’re unprepared. Prevention is always better than crisis response.
