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Rationing creates ethical problems

February 11, 2016

Excerpted from Drug Shortages Forcing Hard Decisions on Rationing Treatment,” New York Times. January 29, 2016 — In recent years, shortages of all sorts of drugs — anesthetics, painkillers, antibiotics, cancer treatments — have become the new normal in American medicine. The American Society of Health-System Pharmacists currently lists inadequate supplies of more than 150 drugs and therapeutics, for reasons ranging from manufacturing problems to federal safety crackdowns to drugmakers abandoning low-profit products. But while such shortages have periodically drawn attention, the rationing that results from them has been largely hidden from patients and the public.

At medical institutions across the country, choices about who gets drugs have often been made in ad hoc ways that have resulted in contradictory conclusions, murky ethical reasoning and medically questionable practices, according to interviews with dozens of doctors, hospital officials and government regulators. Some institutions have formal committees that include ethicists and patient representatives; in other places, individual physicians, pharmacists and even drug company executives decide which patients receive a needed drug — and which do not.

Such decisions have real consequences. The threat of future shortages in children’s treatments is serious enough that Dr. Peter Adamson, who leads the Children’s Oncology Group, the largest international group of children’s cancer researchers, assigned his organization to set priorities. “We’ve been forced into what we think is a highly unethical corner,” he said in an interview.


Commentary

Dr. Omar HamadaCMDA Member Omar L. Hamada, MD, MBA, MATS(c): “Most everyone agrees our healthcare system is in shambles. It seems every proposed and implemented solution simply worsens the myriad problems. It also appears those affected most negatively are the patients and their physicians, while hospitals, insurance companies and pharmaceutical companies continue raking in record profits.

“Hidden in the midst of this is a vital issue that drastically impacts our ability to care for patients. It is a recurring problem we would never expect here in the U.S.—maybe in a third world nation with less than ideal resources, but certainly not here in the U.S. That problem is the continual and recurring shortage of necessary and important medications required for proper medical care and treatment.

“Medications like clindamycin, daunorubicin, Nubain, Stadol, droperidol, Protonix, chloroquine, cisplatin, Phenergan and even normal saline, as well as 150 others, continue to rotate from being widely available to being on nationwide shortages, sometimes for years. This then forces either usage of alternative medications or rationing by use of insufficient dosages or diversion to patients triaged to more desperate need.

“Aside from the obvious logistical, economic and operational issues that both cause and are caused by these shortages, ethical issues come to light in the rationing of resources to patients who are unable to safely tolerate the lack of these medications, or the substitution of these important medications because of clinical requirements. Until this all gets sorted out, we cannot rely on arbitrary decision-making, but we must instead have reasonable and ethical protocols in place that guide rationing and/or substitution.”

Resources

CMDA’s Allocating Resources Ethics Statements
Professionalism in Peril: Unjust Scales in Healthcare by Gene Rudd, MD
Lost and Found: A Consumer’s Guide to Healthcare

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