These are compelling arguments but not persuasive. Consider the following in rebuttal. First, there is no direct evidence that prioritizing stable LVAD patients has prevented other 1A patients from receiving timely transplants. In fact, wait-list mortality has actually gone down (1). It is likely that centers are exercising good judgment by timing these upgrades to avoid competition with other 1A patients, thereby preserving their exposure to donor hearts. Second, before concluding that in the absence of a utilitarian reason there is no rationale to justify 1A prioritization one should be reminded of the German experience (7). In the Eurotransplant system, there is no prioritization for stable LVAD patients, which effectively eliminates the likelihood of their receiving a transplant in the absence of developing a device complication. Choosing to remain in urgent status on medical therapy instead of accepting an LVAD may increase the odds of receiving a transplant but does so at the risk of dying or becoming ineligible while waiting. Patients who opt for watchful waiting but end up requiring bailout LVAD placement have inferior survival while on the waiting list and, among the few who receive a heart, after transplant. Finally, even if one were to craft an entirely new allocation system, disparities in risk would still exist. Consider the authors' own data. Patients supported with paracorporeal ventricular assist devices or mechanical ventilation had risk profiles exceeding those of the other 1A categories, including those who are medically supported or have an LVAD complication.