Clinical and ethical perspectives on rationing of high-cost drugs.
OBJECTIVE
To analyze the use of high-cost drugs from a clinical decision-making approach and ethical perspectives on rationing.


METHODS
The case of a 26-year-old intravenous drug user with AIDS raises issues of how to ration high-cost drugs such as foscarnet, monoclonal antibodies (MAbs) for septic shock, and granulocyte colony-stimulating factor.


RESULTS
Should a patient with a terminal illness receive high-cost drugs given limited healthcare resources? Necessary clinical information including treatment algorithms, risk to benefit ratios, and cost-effectiveness data are evaluated. Rationing, especially bedside rationing, by the clinician is rejected because it is contrary to the clinician's ethical obligation of beneficence and nonmaleficence. Patient autonomy and desires may also conflict with society's interest in equitably distributing resources. Treatment could be denied if costs exceed benefits for the outcomes and thus deny resources to others who have more basic healthcare needs. There is no obligation to offer medically futile care or for the patient to accept extraordinary medical care.


CONCLUSIONS
An ethical argument for rationing cannot be made because of the lack of a clear clinical and societal consensus on specific criteria for rationing of healthcare dollars. The decision to use high-cost drugs in the case presented is made using a clinical decision-making approach based on available treatment guidelines. This assumes that the patient continues to consent to therapy and that there is continued benefit.
Poirier
T I
TI
School of Pharmacy, Duquesne University, Pittsburgh, PA 15282.
Giannetti
V J
VJ
D000163:Acquired Immunodeficiency Syndrome / Q000188:drug therapy; D000328:Adult; D000911:Antibodies, Monoclonal / Q000191:economics / Q000627:therapeutic use; D026686:Beneficence; D003657:Decision Making; D016527:Drug Costs / Q000639:trends*; D004992:Ethics, Medical; D017245:Foscarnet / Q000191:economics / Q000627:therapeutic use; D016179:Granulocyte Colony-Stimulating Factor / Q000191:economics / Q000627:therapeutic use; D015276:Health Care Rationing / Q000592:standards*; D006801:Humans; D008297:Male; D010344:Patient Advocacy; D018579:Patient Selection; D026684:Personal Autonomy; D010595:Pharmacists; D040841:Resource Allocation; D018570:Risk Assessment; D012935:Social Justice
D000911:Antibodies, Monoclonal; D016179:Granulocyte Colony-Stimulating Factor; D017245:Foscarnet