Procedural justice in the deceased-donor pathway before computerised organ matching in China

Computerised organ-allocation systems are designed to standardise clinical criteria, reduce discretionary intervention, and improve traceability. However, matching begins only after potential donors have been identified, referred, authorised, medically maintained, routed through institutions, and entered into the allocation system. Drawing on seven months of multi-sited qualitative fieldwork in China (2017-2018), this article examines how organisational processes upstream of matching shaped allocation pathways during system-building. Participant observation, interviews with 17 professionals, field conversations and documents inform four proposed mechanisms: relational donor visibility, informal referral brokerage, monetised organisational routing, and potential loss of organisational provenance at formal system entry. These mechanisms concern which donations reach matching, through which institutions and jurisdictions, and whether their histories remain traceable; they need not alter algorithmic rankings. From this historical case, the article develops upstream pathway inequality and algorithmic input blindness, and proposes pathway justice as a framework linking entry conditions, routing and matching fairness. The contribution is a conditional proposition: consistent ranking alone cannot secure procedural fairness where upstream pathways remain opaque or unevenly governed. It does not establish the persistence of the reported practices.