Most decisions regarding allocation of scarce medical resources such as organ transplants, and prioritising between patients waiting for organ transplantation, is in most cases straightforward. The empirical knowledge of this issue is limited in Europe compared to the USA. Ethical consideration in decision-making is not acknowledged by physicians of the transplantation community as important or necessary for making the right choice. Medical criteria alone make up the waiting lists. But medical decisions are not as objective as they seem to be. This is a literature review based on empirical and normative knowledge regarding the ethical, legal and medical content of this decision-making in different European countries. There are also some notions about USA and Japan. I have studied the most frequent transplantations practices, i.e. kidney-, heart- and liver transplantations. Regarding ethical dilemmas, public surveys have shown that the public view differs considerably with the view of surgeons, physicians and other members of the transplantation community.There are great differences between countries as regards the use of live donors for kidney transplantations. Due to differences in the organisation of organ procurement the rate of transplantation differs considerably as well. Finally, there is a tremendous variety regarding the public discussions concerning the transplantation laws and the diagnosis of irreversible brain loss. This is due to the different traditions in philosophical thinking as well as different historical experiences. The largest difference between Europe and USA relates to the use of the rigid- almost religious- point system in USA for allocation of transplants.