Health-system scarcity becomes ethically acute when a clinically relevant option is not merely expensive in the abstract but unavailable to a particular patient at a particular moment. This article develops an original normative framework for bedside decisions under such constraint. It distinguishes scarcity from allocation, patient-level constraint, and moral abandonment, and argues that justified limits on what a system can provide do not automatically extinguish duties toward the patient whose options have narrowed. The analysis integrates contemporary work on distributive justice, staffing scarcity, medicine shortages, institutional capacity, triage, moral agency, and procedural fairness. It proposes a persistent ethical floor comprising verification of the constraint, individualized clinical assessment, proportionate mitigation, consideration of clinically reasonable alternatives, transparent explanation, escalation where meaningful, documentation, maintenance of feasible care, and reassessment. The framework then organizes these duties into a branching decision sequence that tests whether the constraint is genuine and system-generated, reducible locally, replaceable by an adequate alternative, sufficiently serious to require escalation, compatible with delay, or contestable enough to warrant independent review. The proposed contribution is not a validated clinical algorithm, legal standard, or universal allocation rule. Its purpose is narrower: to prevent system scarcity from being treated as though it dissolves the therapeutic relationship. The framework remains sensitive to differences in resource type, urgency, institutional authority, jurisdiction, equity, and the practical limits of clinicians acting inside constrained systems.
