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Shortages of some prescription drugs are forcing doctors to make difficult decisions, in some cases choosing one patient over another, or sharing a dose between multiple patients. Hari Sreenivasan learns more about the rationing from Sheri Fink of The New York Times.
Now: how shortages of some prescription drugs are forcing doctors to make difficult, often ethically fraught decisions, in some cases, choosing one patient over another to receive a much-needed drug, or splitting a single dose between two, even three patients.
For a look at what's behind the rationing, how doctors and their patients are coping, and what might be done to correct the problem, we turn to Sheri Fink of The New York Times, who has been reporting on the story. In addition to being a reporter, she is also a medical doctor.
Dr. Fink, what's interesting is, you're talking about some of the best hospitals in the country that are going through this, not a small, faraway hospital where you might expect that there would be a shortage. This is kind of — paint us a picture of how widespread this issue is.
SHERI FINK, The New York Times:
The shortages are affecting all types of hospitals, clinics, broad range of medical specialities. It has touched — in recent years, this problem has touched just about everywhere in America.
So, why is it happening? Is it specific types of drugs? Is it specific companies?
It has to do with, some of the drugs often are made by only one manufacturer. So, if something goes wrong in a quality sense, for example, and they have to shut down production, that could leave the market not having enough.
It could be that there's not an economic incentive for a lot of drug companies to get into this. It could be that manufacturing chains that — in the factories are running all the time, and if one goes down, it can affect lots of different drugs.
So there are economic reasons, there are regulatory reasons. There are all sorts of reasons. And these shortages are becoming a fact of life. They have increased. In recent years, the number of new shortages increased. New federal law requiring manufacturers to tell the FDA if they see something like this on the horizon have decreased the number of new shortages, but the number of existing shortages is quite high.
And, again, it's affecting all different parts of medicine.
All right. So there's a hospital facing a tough choice, saying we have, let's say, five patients that need this drug. We only have enough drugs for two patients. What do they do?
This is the part that we don't see, because, of course, the doctors don't want to make patients feel that — less trustful of their treatment. And these are these tough ethical decisions.
As you said, how do you make these choices? They are not purely medical choices. They have ethical overtones. They have overtones of values. For example, some of the doctors were describing to me about, in some cases, a drug is used for children and adults, and maybe children need less of it. So, could you treat two children with the same amount of drug that you treat one adult?
How do you make that value judgment between lives? It's very difficult.
So, if they're using age as a factor, do they use weight as a factor? Do they use the existing condition of the patient as a factor?
All of the above.
And it's — the point of my investigation — and I have been looking at this for a few years — is that it's being done all sorts of ways. There is no one way. There are very few guidelines. Today, a group children cancer doctors actually published rationing guidelines, because children's cancer, of all the compelling parts of our medical system, that has been hit by shortages in recent years.
And these doctors were so worried, and they had so little ethical guidance, that they said let's get together for a few years, work this through, get ethicists involved, get patient representatives involved, and come out with some strategies for — to offer to doctors who have to make these decisions or who may have to make them.
One of the quotes you have in your stories is, "We have been forced into what we think is highly an unethical corner."
You actually profile — one of the characters in your story is somebody that is essentially working on inventory in the basement of the Cleveland hospital, and he is in a position to decide which one of his clinics and which doctors and eventually which patients will get these drugs.
That quote was from Peter Adamson, Dr. Peter Adamson, the Children's Ecology Group, which is the group that came out with these guidelines in "The Journal of the National Cancer Institute."
And the person you're speaking about is Chris Snyder. So, the Cleveland Clinic has been unusually proactive. They have hired a full-time pharmacist pretty much just to deal with these shortages in recent years. And so Chris Snyder is scurrying around the basement of the Cleveland Clinic, staying on top of these drug shortages and trying — the first step, of course, is to conserve.
It's to wipe out any waste that you might have in your system, and to maximize, so that you don't have to make those tragic choices. But, ultimately, sometimes, they have had to put restrictions on which uses, which groups of patients would get a drug and which wouldn't.
So, what about the patients in all this? You're saying that, oftentimes, they don't even know that the medicine is being rationed to or away from them.
Sometimes, they're not being told. A lot of times, they're not being told. Doctors told me that they don't want to worry a patient. There was a patient I wrote about. Her name is Bev. And she has Crohn's disease, and she relies on intravenous nutrition. So she can't eat like you and I do.
And they cut — during a shortage period that affected many elements of her nutrition, she wasn't told. She wasn't getting zinc and she came up with a horrible rash, ended up in the hospital, and then found out that this was a classic symptom of zinc deficiency. And she said, why didn't anybody tell me?
So, this is just one example of people finding out after. There are many cases what patients just aren't being told. And this is another ethical dimension, is, should patients be told, at what point, and how does the doctor explain the relative risks of a substitute drug vs. the standard drug? It's all very complicated.
Sheri Fink from The New York Times, thanks so much.
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