We read with interest the paper from Roussel et al.1 In this study, the authors examine the outcomes for lung transplant recipients who were allocated donor organs in two very different healthcare systems. Their findings raise the complex and vexed question of what the fairest system for the allocation donor lungs is, especially for those candidates identified as being at the highest risk of waiting list mortality. There are a myriad of different allocation systems in operation across the world, which highlights the complex interplay between medical need, the ethical, legal and societal issues that shape national organ allocation policies.2 3

The paper examines two large national databases over a 10-year period to compare lung transplant outcomes in the French and US systems. The French national lung allocation programme is similar to the UK lung allocation …