When asked which patients receive kidney transplants in England, a social worker attached to a prestigious British teaching hospital recently told me, “Probably the undeserving.” By that she meant that trouble-making patients who lacked the self-discipline to cooperate with dialysis regimes, or who complained the loudest, were often “gotten rid of” by eliminating the need for dialyzing altogether.

Such candor was unexpected, but it points up the fact that even under Great Britain's National Health Service, where egalitarian concerns have always been paramount, criteria other than pure medical need can determine access to organ transplants. Ironically. “negative” social factors provided the key to transplant availability in the cases that the social worker described, although unconventional social factors are probably more often used in the United States to deny the benefits of transplantation to patients who do not fit the middleclass ideal.