Introduction: The shortage of organs available for transplantation has resulted in long recipient waiting lists. This demands fair and objective allocation of the scarce available organs. In most European countries, organs from deceased donors are allocated to patients on the organ waiting list. This implies that donors or their family members cannot determine to whom the available organs will be assigned.

Method: The aim is to address whether directed deceased donation (DDD) should be allowed, and if so under which conditions. Methods include providing a description of the medical and legal context, followed by identification of the main ethical issues involved in DDD, and explore these through a series of hypothetical cases like those encountered in practice. Ultimately, we set certain conditions under which DDD may be ethically acceptable. We restrict our discussion to recipients on the waiting list.

Results: There is a lack of reliable evidence on the frequency of DDD requests and proceeding cases. Directed deceased donation is not addressed in law in most countries since organs of deceased donors are considered as ‘a gift to society’. However, over the last few years Competent Authorities responsible for the allocation of deceased donor organs have been asked on several occasions to permit directed donation. Most requests were made by the next of kin of the deceased, representing the ‘assumed wish’ of the deceased or their actual wish.

Conditional donation such as DDD raises several ethical issues. Arguments for permitting DDD are that; it could increase the potential scope of donor autonomy by enabling them to direct an organ to a family member or friend; in living donation direction to a family member is permitted in many countries resulting in an asymmetry between the living and deceased donation systems. The main argument against DDD is that this violates the basic principle of an altruistic, unconditional gift to society. If DDD is restricted to close family, those with large families are in a much better positions then those who have small or no family around.

Conclusion: From the analysis of the series of hypothetical cases discussed, we can conclude that DDD should be permitted under certain conditions. If these conditions are met, the medical team should do their best to facilitate the wishes of the deceased patient and his/her family by enabling DDD to take place. Letting deceased donors direct their organs to loved ones under carefully controlled conditions will further enhance trust in organ donation and transplantation systems, and hence willingness to become a donor.