**1. Introduction**

Vascularized Composite Allotransplantation (VCA) is a surgical technique aimed at transplanting multiple tissues as a single functional unit, such as skin, muscles, nerves, and bone, with the objective of enhancing the quality of life. Despite significant advancements in surgical techniques, several bioethical challenges remain to be addressed. These challenges encompass various aspects, including the economic burdens associated with the procedure [1], the potential risks of long-term immunosuppressive therapy, such as increased susceptibility to malignancy [2], and the occurrence of acute and chronic rejection [3, 4]. Moreover, the autonomy of patients in choosing a non-life-saving intervention [5] and the

adequacy of psychosocial evaluation tools developed primarily in developed countries [6] are important considerations in the ethical discourse surrounding VCA. Additionally, bioethical concerns extend to the capacity of healthcare teams to effectively manage VCA cases and the need to balance patient suitability for the procedure with the capacity of the country and healthcare system to support such interventions. Finally, definitions regarding transplant success are not straightforward [7]. Although it is true that definitions of transplant success may vary depending on each individual, we believe there must be core domains upon which individual traits can be accommodated.

To address these important considerations, it is crucial to define the success criteria for VCA and establish a framework for evaluating patients, healthcare systems, and the bioethical aspects involved. This chapter aims to examine the bioethical considerations in VCA and propose a preliminary bioethical deliberation model. To achieve this, first, we will try to define success criteria for VCA procedures, based on critical variables that operationalize the principles of beneficence, nonmaleficence, autonomy, and justice. Based on the definition of success, a bioethical deliberation model is proposed to evaluate Deliberative Capacity (to attend to the criteria of Autonomy and Justice), as well as Receiver-Offering Capacity (to attend to the criteria of Nonmaleficence and Beneficence), both on patients and healthcare teams. By addressing these bioethical considerations and providing a clear framework for decision-making, the aim is to ensure that VCA procedures are conducted in an ethically responsible manner, considering the well-being of patients and the integrity of healthcare systems.
