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First Come, First Served in the Intensive Care Unit: Always?


Because the demand for intensive care unit (ICU) beds exceeds the supply in general, and because of the formidable costs of that level of care, clinicians face ethical issues when rationing this kind of care not only at the point of admission to the ICU, but also after the fact. Under what conditions—if any—may patients be denied admission to the ICU or removed after admission? One professional medical group has defended a rule of “first come, first served” in ICU admissions, and this approach has numerous moral considerations in its favor. We show, however, that admission to the ICU is not in and of itself guaranteed; we also show that as a matter of principle, it can be morally permissible to remove certain patients from the ICU, contrary to the idea that because they were admitted first, they are entitled to stay indefinitely through the point of recovery, death, or voluntary withdrawal. What remains necessary to help guide these kinds of decisions is the articulation of clear standards for discontinuing intensive care, and the articulation of these standards in a way consistent with not only fiduciary and legal duties that attach to clinical care but also with democratic decision making processes.

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1. Sisko, A, Keehan, SP, Cuckler, GA, Madison, AJ, Smith, SD, Wolfe, CJ, et al. National health expenditure projections, 2013–23: Faster growth expected with expanded coverage and improving economy. Health Affairs 2014;33:1841–50.

2. Ward, N, Levy, M. Rationing and critical care medicine. Critical Care Medicine 2007;35(2, Suppl.)S102–5. Critical care is characterized by very high expenditures on a relatively few number of patients, many of whom do not survive, and it is therefore a likely place where rationing could occur (at S102).

3. Truog, R, Brock, DW, Cook, DJ, Danis, M, Luce, JM, Rubenfeld, GD, et al. Rationing in the intensive care unit. Critical Care Medicine 2006;34:958–63.

4. American Thoracic Society Bioethics Task Force. Fair allocation of intensive care unit resources. American Journal of Respiratory and Critical Care Medicine 1997;156:12821301.

5. See note 4, American Thoracic Society Bioethics Task Force 1997, at 1283.

6. Some may find this position ethically troubling or at least worth further analysis, but for purposes of this article, we will not discuss this particular issue here.

7. See note 4, American Thoracic Society Bioethics Task Force 1997, at 1283.

8. See note 4, American Thoracic Society Bioethics Task Force 1997, at 1284.

9. See note 4, American Thoracic Society Bioethics Task Force 1997, at 1284.

10. See note 4, American Thoracic Society Bioethics Task Force 1997, at 1284.

11. Cardoso L, McGrion C, Matsuo T, Anami EH, Kauss IA, Seko L, et al. Impact of delayed admission to intensive care units on mortality of critically ill patients: A cohort study. Critical Care 2011;15:R28; available at (last accessed 18 June 2016).

12. These have acronyms such as APACHE IV, SOFA, and TISS. See Knaus WA, Wagner DP, Draper EA, Zimmerman JE, Bergner M, Bastos PG, et al. The APACHE III prognostic system: Risk prediction of hospital mortality for critically ill hospitalized adults. Chest 1991;100:1619–36.

13. One publicized example of a bed-blocker was Scott Crawford, 41years old, who had a failing heart. He had received a heart transplant but shortly thereafter became septic. He experienced kidney and respiratory failure, and required a leg amputation, among other medical complications. He was maintained in the ICU for 11 months, even though his prospects after 6 months were described as “bleak.” His ICU care costs mounted to $2,700,000. See Adamy J, McGinty T. The crushing cost of care. Wall Street Journal, July 6, 2012; available at (last accessed 19 Apr 2016).

14. Wunsch, H, Angus, DC, Harrison, DA, Linde-Zwirble, WT, Rowan, KM. Comparison of medical admissions to intensive care units in the United States and United Kingdom. American Journal of Respiratory and Critical Care Medicine 2011;183(12):1666–73.

15. This is the sort of argument that is often made in re-transplantation cases. See Ubel, PA, Arnold, RM, Caplan, AL. Rationing failure: The ethical lessons of the retransplantation of scarce vital organs. JAMA 1993;270:2469–74. See in reply: Fleck LM. Re-transplantation of major organs: A critical assessment. Unpublished paper, 1994. Readers may request a copy.

16. Neergaard, L. Liver transplant wait depends on where you live. The Huffington Post, October 17, 2015.

17. Fleck, LM. Just Caring: Health Care Rationing and Democratic Deliberation. New York: Oxford University Press; 2009, at chap. 5.

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Cambridge Quarterly of Healthcare Ethics
  • ISSN: 0963-1801
  • EISSN: 1469-2147
  • URL: /core/journals/cambridge-quarterly-of-healthcare-ethics
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