THE BURNED OVER DISTRICT

There are many useful drugs that have been developed and proven effective over the years for all manner of medical needs that are simply not made in a manner that makes enough profit for Big Pharma. Others may have problems with manufacturing or regulatory issues. Whatever the reason, they are in short supply and effect the outcome of patient treatments.

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.

An international group of pediatric cancer specialists was so troubled about the profession’s unsystematic approach to distributing scarce medicine that it developed rationing guidelines that are being released Friday in The Journal of the National Cancer Institute.

“It was painful,” said Dr. Yoram Unguru, an oncologist at the Children’s Hospital at Sinai in Baltimore and a faculty member at the Berman Institute of Bioethics at Johns Hopkins University. “We kept coming back to wow, we’ve got that tragic choice: two kids in front of you, you only have enough for one. How do you choose?”

At the Cleveland Clinic, which has been unusually proactive in dealing with shortages and allowed a reporter access to personnel making decisions about them, one scarce leukemia drug, daunorubicin, was saved for patients in clinical trials, to avoid making the results invalid by substituting another drug. But when a different drug, methotrexate, was in short supply, pediatricians stopped giving it to all patients who required high doses, including those in research trials. “We didn’t want to say just because you’re on a clinical trial you get an advantage,” Dr. Rabi Hanna said.

The article in the NY Times describes some of the efforts to maximize the benefit of scarce drugs but provides no ideas for easing the shortages. At least none that don't call for jacking up the price like Pharma Bro did.