One major consequence arising from the relative shortage of livers for transplantation is that rationing is necessary. The basis for rationing has been subject to much debate. Balancing the sometimes conflicting demands of utility, equity, and justice is difficult, and different health care systems have adopted different approaches to resolving the demands on the supply of organs. One key factor in all systems includes transplant benefit and maximizing the benefit from use of the organ. Recurrence of disease, whether malignant, autoimmune, or other, may reduce graft survival, and in the context of transplantation for hepatitis C virus (HCV), this may have a markedly adverse effect on survival. This is of major importance because end-stage liver disease caused by chronic HCV infection is a leading and increasing indication for liver transplantation. At time of transplantation, the graft becomes infected by circulating virus with serum HCV RNA concentrations peaking at 1-3 months with 10-100 times at 1 year than pretransplantation levels. Histological progression may be rapid, and fibrosis may advance 0.3-0.8 stages per year. Disease progression is accelerated compared with the natural history in the native liver: up to 90% demonstrate histological recurrence at 1 year 1,2 and cirrhosis is found in 30% at 5 years 3 ; the 1-year risk of decompensation in the presence of cirrhosis is approximately 40%. 4 Recurrence may also manifest as rapidly progressive cholestatic hepatitis leading to graft failure in up to 5%. Overall, graft failure rates are greater than in recipients transplanted for other indications, inevitably leading to retransplantation or death, thus resulting in a less effective use of the graft, at least in terms of life-years gained. 5,6