**2. Towards a definition of success in VCA**

To approach a comprehensive definition of success in VCA, it is essential to consider the four fundamental principles of beneficence, nonmaleficence, autonomy, and justice, with critical variables serving as a solid foundation for defining and operationalizing these principles.

#### **2.1 Non-maleficence and beneficence**

To precisely define the concept of beneficence in the context of VCA, it is essential to revisit the procedure's bioethical justification: the enhancement of quality of life. Quality of life is intricately tied to the processes of multisystemic resilience, which enables individuals and their support networks to cope with adversity and continue pursuing their goals and aspirations despite challenges.

The focus on resilience as a key variable for success should guide bioethical deliberation. We propose to pay special focus on Objective Resilience, as an indicator that encompasses both key multisystemic resilience domains, as well as important quality of life domains as measured by the WHOQOL [8] and SF-36 [9]. Therefore, it is important to define what multisystemic and objective resilience entails.

#### *2.1.1 Multisystemic resilience*

According to Ungar [10], resilience is a complex and multisystemic phenomenon that extends beyond individual characteristics. It recognizes that an individual's ability to navigate and overcome adversity is intricately tied to the availability,

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

accessibility, and meaningfulness of critical resources within various systems that encompass different domains of life that directly or indirectly impact an individual's ability to navigate and overcome adversity. According to Bronfenbrenner's Theory of Social Ecology [11], these systems include the individual, their close support networks such as family and healthcare teams (microsystem), the interactions between different microsystems (mesosystem), broader social structures that influence mesoand microsystemic relationships (exosystem), cultural norms, laws, and customs (macrosystem), and the temporal dimension within which these systems interact and change (cronosystem).

This multisystemic perspective allows individuals or communities to engage in processes of recovery, adaptation, and transformation. Recovery, as described by Ungar [10], involves returning to a state equal to or better than before the adversity. It signifies the ability to regain equilibrium and restore functioning after experiencing challenges. Adaptation, on the other hand, refers to the process of positively adjusting to changes brought about by adversity. It entails developing new strategies, skills, and perspectives to effectively cope and thrive in the face of challenges. Lastly, transformation occurs when systems are improved as a result of navigating and overcoming adversity. It signifies the potential for growth, innovation, and positive change within individuals, communities, and even larger societal structures.

#### *2.1.2 QoL-objective resilience*

Resilience, at any level, is achieved through the availability, accessibility, and meaningfulness of critical resources within multiple systems. This inherently multisystemic nature of resilience forms the foundation for objective resilience. Objective resilience, as emphasized in the bioethical deliberation model, encompasses both immediate contextual domains that directly support QoL—such as support network's material stability, access to environment, independence in relation to physical and emotional limitations, and social functioning—as well as individual domains, such as physical pain, physical energy, physical limitations, psychological well-being, psychological limitations, and individual material stability. These dimensions provide a comprehensive understanding of an individual's overall functioning and the impact of different factors on their quality of life.

By considering these factors, objective resilience serves as a critical material variable that underpins the moral justification of VCA. The underlying promise of VCA is to improve resilience via the increase of availability, accessibility, or meaningfulness of critical resources both for objective resilience domains, as well as those of multisystemic resilience. Thus, defining transplant success involves increasing objective and multisystemic resilience not only in terms of recovery, primarily through treatment adherence, but also in the patient's adaptation and the transformation of the healthcare system.

#### **2.2 Autonomy**

Autonomy, a fundamental principle of bioethics, plays a vital role in informed consent and medical practice. Autonomy is characterized by self-governance and personal causation, reflecting an individual's ability to make autonomous choices. Respecting patient autonomy plays a crucial role in defining the success of a transplant as it recognizes their ability to deliberate and make decisions regarding their treatment [12]. Autonomy forms the foundation for informed consent to be considered valid [13–15]. Several factors must be evaluated by practitioners to determine the validity of patients' informed consent, including competence, disclosure, comprehension, voluntariness, and agreement [13].

Psychological assessments are commonly used to assess the capacity of transplant candidates to provide informed consent. However, these assessments primarily focus on cognitive vulnerabilities that may impede understanding. While voluntariness and agreement are essential aspects of informed consent, the psychological factors involved are often overlooked due to their challenging measurability and susceptibility to deferential vulnerability: pressures that prompt patients to "accede to the perceived desires of certain others notwithstanding an inner reticence to do so" [16]. Such vulnerability—among others—compromise consent. Despite its relevance, currently, psychosocial evaluations of patient candidacy do not specifically address the assessment of autonomy in relation to deferential vulnerabilities [17]. To bridge this gap, we propose and continue developing a theoretical framework (*under review*) informed by a Kantian interpretation of Honneth's Recognition Theory [18, 19], emphasizing the importance of self-relationships and human dignity. This framework is complemented by **Figure 1**, which shows key moments of the theory, as well as indicators for its observation.

#### **Figure 1.**

*Bioethical principles in the bioethical deliberation model. Note: QOL-objective resilience is at the center, overlapping with both autonomy of the patient, and justice of the healthcare team. QOL-objective resilience has three levels: Recovery (non-maleficence), adaptation (beneficence), and transformation (beneficence). Autonomy is divided into positive and negative freedom. Some further annotations are included per domain.*

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

According to Honneth's Theory of Recognition [18, 19], essential self-relationships precede autonomous functioning and include self-trust, self-respect, and self-esteem. Although these definitions highlight relevant social values, we believe that it is important to also think about the self-relationships described through the light of a Kantian vision to further highlight a non-movable value—human dignity. The concept of value necessitates a comparison between objects based on a criterion that bestows worth. In Western culture, self-worth adjustment typically occurs through two distinct avenues. The first involves oppressive socialization, where individuals conform to societal standards of beauty, wealth, and intelligence. This process leads to the development of "contingent self-esteem" also named "contingent self-worth, " which depends on meeting specific standards of excellence as outlined by interpersonal or intrapsychic expectations. Alternatively, Kant would argue that self-worth should be based on the unchanging axiom of dignity, which allows no degrees and remains an absolute value despite an individual's failure to meet social standards.

Self-relationships are closely connected to self-worth, which can be understood through the concepts of dignity and respect. Respect, based on Kantian principles, involves treating others as ends rather than means [20] and refraining from abusing someone's vulnerable position in which he or she may be treated as if they were undeserving of dignity—for reasons such as those conveyed by oppressive socialization [21]. Self-respect refers to the ability to treat oneself with dignity and recognize one's absolute value, which cannot be achieved or lost based on external standards or failures. Trust emerges as the expectation that arises from respecting dignity despite flaws, helping to maintain one's worth even when faced with shortcomings. Self-trust is the expectation that one's dignity will be defended and treated with respect by oneself, irrespective of societal expectations or oppressive standards, such as those related to beauty—that oppressively subjugate people's self-recognition of dignity and worth. Self-esteem is a psychological measure of how individuals perceive their relational value and social acceptance by others, as proposed by the sociometer theory [22]. It involves adopting the perspectives and judgments of others, and it fluctuates based on accomplishments and social recognition [23]. It is determined by what is deemed socially valuable or repugnant [24].

The argument goes as follows: if a patient seeks a VCA to increase self-esteem (via diminished social rejection), and so to conceal his or her notion of low selfworth, deferential vulnerability to accept the risks of receiving a transplant is likely to be present. Ways to assess deferential vulnerability are proposed later in the chapter.

#### **2.3 Justice**

Justice, as a critical component of transplant success, extends beyond equitable resource allocation to include sensitivity to factors that can bias and impede fair deliberation. We believe transplant success should imply a just bioethical debate that considers objective resilience as the foundation of quality of life and be free of oppressive socialization biases (societal norms, values, and prejudices that may unfairly influence individuals' beliefs, choices, and opportunities [21]). Under oppressive socialization, medical professionals may face external expectations to offer VCA as a solution to patients, even when it may not be the most appropriate or beneficial option. These pressures can stem from societal beliefs regarding beauty standards, the desire to showcase medical advancements, economic considerations, among

others. On the other hand, oppressive socialization can perpetuate biases that may unconsciously influence the medical team's perception of patients, potentially leading to unequal treatment, disregard for patient autonomy, or inappropriate candidate selection. It is important to recognize and address these biases to ensure fair and just decision-making processes.

Overall, justice as a component of transplant success requires not only fair resource allocation but also a commitment to promoting objective resilience and ensuring that ethical deliberations are free from oppressive socialization biases.

After operationalizing each principle, we can say that *transplant success in the context of VCA involves a procedure that is autonomously chosen by the patient and fairly allocated by the healthcare team. It aims to effectively promote patient objective resilience, while also addressing the patient's main motivations and facilitating recovery, adaptation, and transformation.*

Based on the proposed definition of transplant success, a process is proposed that seeks to evaluate and promote the conditions for the possibility of transplant success. For this, the bioethical deliberation model has been outlined. This model encompasses an assessment of both the patient's and the healthcare system's capacity, focusing on two dimensions: deliberative *capacity* and *receiver-offering* capacity. By evaluating these aspects, the model aims to ensure a thorough and comprehensive evaluation process that upholds the principles of beneficence, non-maleficence, autonomy, and justice. It seeks to minimize the impact of oppressive socialization biases and promote a fair and ethical approach to decision-making in VCA.

In this chapter, the elements of the bioethical deliberation model are described both for patients and healthcare teams. In addition, methods or tools for the evaluation or exploration of the domains are described or proposed for either the patient or the healthcare teams.
