Cardiogenic shock remains one of the main challenges in modern cardiovascular medicine. In Spain, urgent cardiac transplantation is the most widely used heart replacement therapy fin eligible patients who do not achieve cardiac recovery. However, this approach has significant implications related to the principle of equity, influenced by the characteristics of the recipient, the donor, and organ access. When selecting a recipient, multiorgan failure must first be addressed before considering transplantation. At the same time, it is essential to expand the donor pool through various strategies to meet the growing demand, even if it involves using suboptimal organs. Given the scarcity of donors and favorable outcomes, long-term left ventricular assist devices should be considered as an alternative to transplantation. Finally, designing organ distribution criteria remains a constantly evolving challenge, as there is no universal system that can address all the issues involved. Allocating organs to the most critically ill patients can provide substantial individual benefits, as long as it does not significantly compromise the common good.