• BC
    Shortages of various medicines occur. Drugs for cancer, anesthesia, surgical bleeding control, intravenous nutritional supplements, autoimmune disorders, etc. can end up in short supply for various reasons relating to manufacturing difficulties, safety regulations, sudden increased demands, and bottlenecks of various other kinds. About 150 drugs are currently (and temporarily one hopes) in short supply.

    FDA List Website

    Doctors have to make difficult decisions:

    -- Cancer drug: treat two children (smaller doses) or 1 adult?
    -- Anesthesia drug: tell the patient and/or family that he or she didn't get something normally given, or not?
    -- Cancer drug: delay treatment or substitute a drug that is available but not as good?
    -- Intravenous nutrition supplement: tell the patient that some essential ingredient is missing, or not?
    -- When there are few antibiotics that work on an infection, and what works is in short supply, should one wait for resupply to treat (and perhaps lose the patient) or take the extreme measure of amputating the infected limb before the infection spreads?

    These are difficult decisions because it is obvious what should be done, but can not be done at the moment. The nature of supply and distribution problems is such that manufacturers and regulators can't tell the doctors when the drug will be plentiful again.

    If you were the hospital on-call ethicists, what would you recommend?
  • Hanover
    There needs to be a specific system for rating priority that removes the subjective judgment element so that it can be carried out the same by everyone. That is, who gets the drug shouldn't be determined by who happens to be presiding on the death court that morning.

    As to the specific criteria, I'd think it'd be the same as who should get the next kidney, the next heart, or the next ear. Those sorts of decisions have to be made all the time. Since there is often really no perfect answer, the best we can do is be consistent and create a fair process.

    It's a twist on the age old question of who to throw out of the sinking boat in order to save it from sinking and killing everyone: the priest, the rabbi, or the prostitute. I mean, you throw out the rabbi, what's a priest going to do with a prostitute (especially if she's a female)?
  • BC
    The article indicated that formal standards do not exist because, to a large extent, the problem has not been openly acknowledged among staff and administrators, let alone with patients. Also, these are generally temporary situations. One month it might be one drug, next month a different one altogether. One rule would not fit everyone in all times and places.

    In addition to the problem of devising a rule, there is the problem of the new patient with unanticipated problems needing a drug that happens not to be available. It's midnight. The patient is very sick. The doctor can't convene an ethics committee to provide guidance.

    For anesthesia medications, one interviewed doctor said, "the patient isn't awake and the family isn't there, so why bring up the fact that a chemical normally used isn't available? Not having the drug is tolerable, but not optimal. Why cause a great deal of consternation in the patient by telling him or her the night before surgery, "By the way, we're out of one of the drugs for your anesthesia. You'll probably be just fine!"

    If you have only 6 ounces of potent cancer chemo compound that will treat 2 children or one average sized adult, what standard should one use to choose the children or the adult? What if the patient weighs 300 lbs. and is just a bit too heavy for the amount of drug available. Skip the 300 pounder for the two 75 pounders? Someone will suffer either way.

    What principle should tip the scale toward the children or the adult?
    I would not consider these ethics issues.

    These are triage issues.
  • BC
    These are triage issues.YIOSTHEOY

    Are there no ethical questions in carrying out triage?

    I think of triage as simply the logical allocation of scarce resources.

    The only ethical consideration would be to be fair and consistent in your judgments.

    The 1's are the ones who are most worth trying to save because they have the greatest chance of making it through alive.

    The 2's are the ones that are ok to try if practicable.

    The 3's are going to die anyway so just make them comfortable and get them a drink or something.
  • BC
    If you were doing triage, and one person had a 40% chance of surviving, but was developing a critically needed new antibiotic, and the other person had a 60% chance of surviving, but was a 3 times convicted rapist, which one would you spend the most time trying to save?

    Triage does not concern itself with the administration of criminal justice.
  • BC
    Of course not. Nobody asked you to administer criminal justice.

    But... people with criminal records and people doing important work both end up in accidents, bombings, fires, crashes, etc. In this example, you know that one person is a convicted rapist, the other is doing very important research. It is quite possible that in real life a doctor might know something about two patients that would make triage a more ethically freighted decision.

    You are being asked to apply your ethics to a possibly difficult choice. Medicine rather often presents us with difficult ethical choices. Life, in general, does that every now and then.

    "... but ..." is where you are making the issue really complex.

    Prison inmates get treated a certain way and have certain resources afforded to them. While they are inmates I doubt they are very high on the list for organ transplants and exotic medical treatment.

    Once they finish their sentences and are discharged, then they return to society and should be treated like anybody else.

    That's the only philosophical issue -- the ethics of how you triage.
    It's funny Old Cranko how you use all sorts of tricks to shift blame back to others whom you are addressing. I am guessing you don't have a lot of friends left.
  • BC
    Blame? I'm just trying to goad you into a discussion about medical ethics.

    I do not goad well.

    You had best try sweetness and sugar instead.
  • BC
    I merely wish to benefit from your lovely, energetic, frequent, sometimes obtuse posts.


    Love you, honey,

  • BC
    I do not goad well.YIOSTHEOY

    That, of course, is not my problem. I goad well. YOU, on the other hand, do not move like the other cattle. You clearly march to a different drummer. You are an independent thinker.

    I do not flatter well either. Just try being polite.
  • BC
    And when was I not polite to you?
  • SherlockH
    1.two lives are more then one, theyll live longer choose the kids 2. If it doesnt effect if theyll die/live and procedure goes normally, or you can fix it "mums the word" 3. substitute the drug if time is running out 4. if it doesnt change anything dont tell them or fix the problem 5. If time is too short cut the limb, if not wait ( though that can go either way) I think both might be right. (Most of these are not hard choices)
  • Benkei
    How does triage deal with an adult and a child with the same illness and equal likelihood to survive? Or two adults one of which is a man the other a woman? Or two adults, one of which is a KKK-member and the other President Trump?
  • Sum Dude
    How about the Amish (maybe Jehova's Witnesses?) refusing their children blood transfusions. That's a good'n.
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