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The mortality of CDH neonates remains high despite neonatal intensive care improvements [8]. The reported 24-h mortality ranges between 21–31%, whereas the 1-year mortality can be as high as 46% [9]. There are limited published literature on the outcomes and associations of RB-CDH.Aim Our study aimed at investigating the clinical characteristics and analyzing the risk factors of survival in neonates with RB-CDH treated in our center over a period of 13 years. Methods We conducted a retrospective study of all infants with RB-CDH treated at our tertiary care hospital between January 2005 and January 2018. The inclusion criterion was a diagnosis of RB-CDH. Infants who had diaphragmatic eventration were excluded. The diagnosis of RB-CDH was made by prenatal ultrasonographic scans, plain chest radiography films, or contrast-enhanced computerized tomography in doubtful cases. Cardiac malformations were diagnosed using two-dimensional (2D) echocardiography. The following variables were assessed: gestational age, mode of delivery, Apgar score at 1 and 5 min, birth weight, associated anomalies, duration of mechanical ventilation, and the severity of pulmonary hypertension, in addition to the surgical approach, timing of repair, need for a surgical patch, postoperative complications, and recurrence of hernia. Data are presented as an absolute number with a percentage or mean ± standard deviation. A univariate analysis was performed to describe demographic and perioperative data. A comparison between two groups (group A = survivors/group B = non-survivors) was performed using a Student’s t test for continuous variables and Fisher’s exact test for categorical variables. A P value <.05 was defined as significant. The statistical analysis was performed using the statistical software (IBM SPSS Statistics for Windows, Version 22.0., IBM Corp, Armonk, NY, USA). We identified 15 infants with RB-CDH during the study period (Fig. 1). Most of the patients were full term (74%). The mean birth weight was 2.90± 0.72 kg. There were 10 males (67%) and 5 females (33%) with a male to female ratio of 2:1. Seven newborns (47%) were delivered by cesarean section, and eight were delivered vaginally (53%). The mean APGAR score was 5.31±2.34, and 7.30±1.59 at 1 min and 5 min, respectively.All patients were diagnosed from prenatal ultrasound and/or radiological imaging after birth, with the clinical signs of tachypnea, apnea, bradycardia, desaturation to Spo2 less than 90% and scaphoid abdomen. Ten patients (67%) were diagnosed by antenatal ultrasound. RB-CDH was found only in 6 fetuses (40%), 2 fetuses (13%) had signs of hydrops (pleural effusion, pericardial effusion, and ascites), and 2 (13%) had only polyhydramnios. different levels of such systems, including national (e.g., France and The Netherlands) or regional (the Swedish system) [1] However, regardless of where decisions are made, the strong norm of equality in such systems will require standardization regarding what is reimbursed. Determination of this standard depends on the size of the healthcare budget, which introduces ‘borderline’ effects (i.e., types of healthcare interventions found both ‘inside’ and © The Author(s). 2020 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. * Correspondence: lars.sandman@liu.se 1 National Centre for Priorities in Health, Department of Health, Medicine and Caring Sciences, Linköping University, S-581 83 Linköping, Sweden 2 Västra Götaland Region, Sweden Full list of author information is available at the end of the article Sandman and Hansson BMC Medical Ethics (2020) 21:94 https://doi.org/10.1186/s12910-020-00539-6 ‘outside’ of the budget). One such area is plastic surgery, whereas another might be assisted reproduction. Some areas of plastic surgery, such as reconstructions after trauma, burns, cancer, and congenital malformations, should indisputably be part of a publicly funded healthcare system. However, other interventions are more disputed, and there is ongoing discussion regarding reimbursement and rationing in plastic surgery [2– 4]. Even under these conditions, the threshold concerning what should be offered in a publicly funded system remains to be determined. For example, how many cosmetic corrections should patients be offered, and what type and degree of defects should patients have to accept? Analyses of guidelines from England [5, 6] describe the existence of a postcode lottery concerning whether or not plastic surgery is offered as part of public healthcare, indicating the difficulty to agree on a common, evidence-based, and clinically applicable sorting method [4]. Moreover, there is increasing pressure from citizens to offer plastic surgery in the publicly funded healthcare system based on the perceived changes in need and expectations according to influences from the media [7, 8], Internet [9], and social factors [10]. The aim of this article is to normatively analyze different suggestions regarding how publicly financed plastic surgery should be delineated in order to identify a wellconsidered, normative rationale. The scope of the article is to discuss general principles rather than define specific conditions or domains of plastic surgery that should be treated within a publicly financed system. In plastic surgery, there have been attempts to distinguish between what should be reimbursed or rationed by differentiating between functional and non-functional conditions, reconstructive and esthetic surgery, and normal and abnormal status, as well as by referring to different condition-specific etiologies [4]. The American Medical Association (AMA) uses the following definitions of ‘esthetic’ and ‘reconstructive’ surgery:” Cosmetic surgery is performed to reshape normal structures of the body in order to improve the patient’s appearance and self-esteem. Reconstructive surgery is performed on abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease. It is generally performed to improve function but may also be done to approximate a normal appearance” [11]. Here, we will show that this does not provide adequate guidance for priority setting. Additionally, there is a recurrent discussion concerning the role of subjective perceptions or preferences by the patient in deciding whether plastic surgery should be reimbursed [4, 6]. We have not found any in-depth normative analysis of these different suggestions and their internal relationship. Our analysis has the following outline. First, we explore the distinction between functional and nonfunctional conditions. We then focus on non-functional conditions and explore the role of patient preferences, subjective experiences, and normality relative to nonfunctional conditions. In exploring normality, we evaluate whether different etiologies of a non-functional condition should make a difference in whether the problem can be assessed as norm. The article ends with our central conclusions. Methods This analysis uses a reflective equilibrium approach, according to which considered normative
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