**3.4 Case example**

The evaluation process begins with a thorough assessment of the patient's autonomy and deferential vulnerability through clinical and psychiatric interviews, as described in the corresponding section. A comprehensive multisystemic evaluation is then carried out to estimate the potential effect of the transplant on the patient's objective resilience and quality of life. This evaluation encompasses various domains, as summarized in **Table 1**, and takes into account the estimated effects on objective resilience as depicted in **Figure 5**. **Table 1** presents the main domains with key information regarding the presence of risk factors or contraindications. This information allows us to quickly review the patient's current systems' resilience and the expected impact of VCA on patient objective resilience.

Preliminary deliberations with the subcommittee are guided by fundamental principles such as respect for physical life, totality, subsidiarity, and freedom and responsibility. Respect for physical life serves as a boundary when considering interventions. Totality emphasizes that any intervention will affect the entirety of the person's life domains. The principle of subsidiarity is crucial as it calls for a generous attitude, especially in developing countries and when working with vulnerable populations. Finally, freedom and responsibility highlight the notion of being free yet accountable for all aspects of life.

Aligned with these principles, deliberations are held to define the next steps after discussing the current risk factors that predict harm as an effect of VCA. Strategies are proposed to improve patient candidacy and the effect of VCA on the patient's


#### **Table 1.**

*Summary of a preliminary multisystemic psychosocial evaluation.*

#### *Defining Success and Ethical Decision-Making in Vascularized Composite Allotransplantation… DOI: http://dx.doi.org/10.5772/intechopen.112296*

objective resilience and quality of life. For example, enlisting the patient for job security. As the patient's candidacy evaluation progresses, ongoing evaluations and training sessions are provided to the healthcare team and VCA subcommittee, tailored to the Mexican context. Additionally, continuous assessment of the capacity to offer VCA is conducted, allowing for iterative improvements in processes, with the ultimate goal of achieving transformation and optimizing outcomes.

It is expected that after systematically following the proposed bioethical deliberation model, the conclusion would be that the patient has autonomously deliberated with knowledge and understanding of the risks and benefits, without a determining pressure to conform to social expectations, and that they desire VCA as a practical strategy to achieve their goals. In addition to having the capacity to weigh and decide, in the case of a successful transplant, it is expected that the patient actively engages to enhance their understanding and deliberative capacity, and they co-create the therapeutic strategy with the healthcare team. On the other hand, a successful VCA case also entails that the individual, as well as their environment, has availability and access to critical resources to 1) prevent, resist, and overcome adversities related to VCA treatment (thus achieving non-maleficence *recovery*) and 2) positively *adapt* to their life circumstances with VCA (resulting in a beneficial effect). Additionally, a successful VCA case implies that the healthcare system has the necessary means to ensure non-maleficence and recovery in the patient's objective resilience and to guarantee beneficence and adaptation in the patient's objective resilience and quality of life. Finally, it also signifies that the healthcare system has the necessary mechanisms to improve and transform the system and the conditions that improve the multisystemic resilience of the population.

### **4. Discussion**

In the realm of VCA, ethical deliberation plays a pivotal role in safeguarding the well-being of patients and guiding healthcare systems. To address the intricate considerations surrounding VCA and foster informed and ethical decision-making processes, the proposed bioethical deliberation model represents a significant advancement.

Built upon the fundamental principles of beneficence, non-maleficence, autonomy, and justice, as well as the principles of Personalist Bioethics, the model is crafted to align with the bedrock of ethical healthcare practices. By focusing on three key dimensions, namely deliberative capacity, reception-offering capacity, and the deliberation & subsequent design phase, the model provides a robust framework for evaluating and promoting the readiness and suitability of both the patient and the healthcare system for VCA.

At the heart of the model lies the recognition of objective resilience as a critical determinant of success and a catalyst for patient well-being. Objective resilience encapsulates an individual's capacity to navigate, withstand, and triumph over adversities, thereby enhancing their overall quality of life. By adopting a multisystemic approach to assess objective resilience, the model enables a comprehensive evaluation that takes into account the interconnectedness of various systems contributing to an individual's resilience.

In conclusion, the proposed bioethical deliberation model offers a structured and comprehensive approach to evaluate VCA procedures, facilitate ethical decision-making, and elevate patient care and treatment outcomes. By thoughtfully considering the critical variables that define beneficence, non-maleficence, autonomy, and justice, this model provides valuable insights into navigating the intricacies of the ethical landscape surrounding VCA. Ultimately, the model serves as a guiding compass for enhancing the well-being of both patients and healthcare systems, exemplifying the ethical aspirations of the VCA field.
