There are around 7,000 people on the transplant waiting list in the UK at any given time. Last year, approximately 1,000 people died waiting. The fundamental problem is arithmetic: there are not enough donor organs, and there never have been.
The question of who receives an organ first is therefore not theoretical. It is a real decision, made by real systems, with life-or-death consequences.
The current UK system
NHS Blood and Transplant (NHSBT) allocates organs using a combination of factors that vary by organ type. Urgency of need — how close to death the patient is — is weighted heavily. Compatibility is essential: blood type and, for kidneys, tissue type matching reduces rejection risk. Time on the waiting list plays a role. Expected benefit — how likely the transplant is to succeed and how many life-years it is likely to add — is also considered.
The system attempts to be objective, algorithmic, and transparent. It isn’t entirely. Clinical judgement enters at multiple points.
The utilitarian argument
One approach would be to give organs to those who will benefit most — measured in quality-adjusted life years (QALYs) gained. This would tend to favour younger, healthier patients with fewer comorbidities, since they are likely to survive longer with a functioning organ.
The problem is that pure outcome maximisation conflicts with equality and urgency. Under a strict QALY model, an older or sicker patient might never reach the top of the waiting list — their expected benefit is lower at every point, however long they wait.
The egalitarian and desert-based arguments
An egalitarian approach emphasises equal claim to scarce resources regardless of expected outcome. A utilitarian would say this wastes organs. An egalitarian would say that medicine shouldn’t operate on a first-come basis among the living.
A more contentious dimension is the question of lifestyle factors. Should someone who has continued smoking receive a lung transplant? Should a patient who has relapsed into alcohol use receive a liver transplant? The UK system does not formally exclude patients on these grounds — addiction is recognised as a medical condition — but the evidence of sobriety typically required before listing reflects a practical rather than purely moral judgement.
International variation
The US system is explicitly more utilitarian in some respects. Spain, which has one of the world’s highest donor rates, operates on presumed consent — citizens are assumed to be organ donors unless they have opted out. England moved to this model in May 2020.
Whether presumed consent raises donation rates significantly is contested. Spain’s high rates are attributed by many researchers more to its specialist coordinator system than to the legal default. The evidence from England’s transition is still accumulating.