Purpose <p>Liver transplantation, a life-saving procedure, stands as a pinnacle of modern medicine’s capacity to extend life and alleviate suffering. However, the process of organ allocation poses complex ethical challenges, particularly concerning elderly patients. This article delves into the intricate interplay between justice, equity, and utility in the context of liver transplantation for the elderly.</p> Findings <p>Justice serves as a cornerstone principle, demanding fair distribution of healthcare resources. Advocates argue for utilitarian principles, prioritizing those with the greatest potential to benefit. Depending on how this approach is applied it risks marginalizing elderly patients, perpetuating ageism in healthcare. Striking a balance necessitates a nuanced understanding of equity. Equity demands a holistic evaluation, encompassing not just medical criteria but also patients’ overall well-being, functional status, and social support systems. It requires recognizing the inherent dignity and value of every individual, regardless of age. Utility, intertwined with justice and equity, underscores the imperative to maximize societal benefit. Optimizing utility involves judicious allocation of these resources to yield the greatest aggregate benefit, but determining the definition of benefit can vary. By not acknowledging the unconscious bias of age, it risks exacerbating disparities and undermining trust in the healthcare system.</p> Summary <p>We herein explore the intricate dynamics involved in decision making for distribution of liver transplants amongst elderly patients, emphasizing the necessity of balancing justice, equity, and utility. Highlighting the importance of a comprehensive assessment, in line with the legal mandate of the Final Rule, we discuss a balanced approach that looks beyond chronological age when considering liver transplant.</p>