Ethical integrity in managing drug shortages

Consider the hypothetical case of two patients at a hospital who both need a drug that has just become in short supply. The pharmacy has enough for only one patient. Patient A’s physician is pressuring the pharmacy to make the product available to his “VIP patient.” One pharmacist in the department argues strongly not to release the product yet to allow time to research a gray-market source. This pharmacist says that he knows who can get products when these situations arise and that the source can be trusted. The pharmacy director agrees and asks that a large quantity purchase be explored but also indicates that the pharmacy-developed allocation protocol must be quickly instituted—time is of the essence. Three very challenging ethical issues have surfaced at this point. The first deals with the allocation of a product in scarce supply, which is essentially a question of rationing. National Public Radio aired a story on this exact issue on October 3, 2011.1 While questions about rationing care are not new in medicine, this is relatively uncharted territory for pharmacy. Point 8 of the Code of Ethics for Pharmacists provides the following guidance on allocation:“When health resources are allocated, a pharmacist is fair and equitable, balancing the needs of patients and society.”2 But if two patients have an immediate need for the product, and the supply can only meet the need of one, then what is fair? Do we give it to the “VIP patient”? Do we give it to the younger patient with more years to live? Do we give it to the person who can pay?