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All newborns were diagnosed by chest X-ray, but four of them needed chest CT scans to confirm the diagnosis. More than quarters (27%) of the parents were consanguineous. Nine mothers did not have any medical illness (60%), whereas four (27%) had DM, VSD, or hypothyroidism. Two mothers (13%) had multiple abortions. Eleven patients survived to undergo repair with laparotomy. One patient needed an additional right thoracotomy for hepatopulmonary fusion. The liver was the most frequently herniated organ—found in 10 patients (91%)—followed by small bowel (82%) and large bowel (36%). The hernial sac was found in five patients (45%).Most hernial defects were closed primarily using either polypropylene, silk, or polyester sutures. Polytetrafluoroethylene (PTFE) mesh was used in one patient with a large defect and transversus abdominis muscle flap was fashioned to close the defect in another patient. The mean age at the operative repair was 8.11±9.90 days. The average NICU stay for all patients was 40.47±50.38 days.The mean follow-up period was 20.45±9.34 months. Three patients had postoperative complications, two had an incisional hernia, and one had GERD. One patient had recurrences twice, which mandated mesh repair at the age of 6 months. The total survival rate in neonates with RB-CDH was 9/15 (60%), and two (18%) died postoperatively from severe persistent pulmonary hypertension of the newborn (PPHN) and cardiac complications at the age of 2 months and 9 months, respectively. Four patients (27%) died early after birth (before the surgical repair), three of them died on the first day of life, and one died at the age of 22 days. Ventilation-related bilateral pneumothorax was a contributing cause of death in three patients. Nine out of eleven (82%) neonates survived after surgical repair.When a comparison was made among the survivors (n =9) and non-survivors (n =6) (Table 1), birth weight was found lower in non-survivors, which was statistically significant (P < 0.05). Moreover, the degree of pulmonary hypertension was more severe among non-survivors. There was no statistically significant difference in gestational age, Apgar score, and cardiac malformations between RB-CDH survivors 9/15 (60%) and non-survivors 6/15 (40%). The details of cardiac abnormalities are shown in Table 2. Though most of the dead patients required HFOV (83.33%), the result was not statistically significant compared to only 44.44% of the survivors. Two of the survivors had associated non-cardiac anomalies (undescended testicle, grade1 hydronephrosis, and hydrocephalus). It was noticed that the average number of days of mechanical ventilation (HFOV and conventional ventilation) in the survivor group was 14.33±9.77days. CDH has been recognized as a syndrome, including diaphragmatic defects, pulmonary hypoplasia, and pulmonary hypertension [10, 11]. Some authors have observed a female predominance for a Bochdalek hernia; however, others have observed a male predominance [12]. In our study, also male preponderance was noted in RB-CDH. Neonates with CDH are at risk for prematurity and low birth weight (LBW), which predisposes them to increased mortality [13, 14]. judgements in one area should be coherent with considered normative judgements and background theories within a system at large [12, 13]. Specifically, this requires identification of general principles for distribution of scarce resources in the healthcare system and how those principles are applied when distributing resources in other parts of the healthcare system. Additionally, it requires analysis of whether this is consistent with suggestions regarding how to delineate public funding of plastic surgery identified in the literature. Moreover, these principles and the normative judgments they imply, should also be consistent with the empirical environment in which they are applied, in this case empirical data about how different relevant conditions affect patients, how plastic surgery can treat those conditions and the resulting effects on patients etc. Coherence implies logical or argumentative coherence, hence applying a reflective equilibrium methodology means showing through logically consistent argumentation whether suggestions can be supported or not. Coherence does not necessarily imply agreement between different stakeholders or individuals, any such disagreement has to be supported by pointing to flaws in the analysis or argumentation. In this article we will analyze a number of considered judgements (see below), explicitly or implicitly found in the literature or in practice against a set of normative principles for distributing scarce resourses [14]. In this study, we make the following assumptions about normative principles for guiding resource distribution in a publicly financed, welfare-type healthcare system: 1) only healthcare needs should be treated within publicly funded healthcare systems (what we will call the principle of exclusivity of needs or PEN for short); 2) the greater the size of the healthcare need, the more warranted it is to receive funding ceteris paribus (what we will call the principle of size of needs or PSE for short); 3) if the treatment of similar problems is funded elsewhere in the healthcare system, this requires a special reason not to fund it within the context of plastic Sandman and Hansson BMC Medical Ethics (2020) 21:94 Page 2 of 14 surgery and vice versa (what we will call the principle of formal equality or PFE for short) [15]. The analysis is undertaken relative to publicly financed, welfare-type, and needs-based healthcare systems, such as the British National Health System or the Scandinavian healthcare systems. Because the focus of the analysis is on distribution of scarce resources (i.e., distributive justice), other relevant clinical ethics considerations related to principles of beneficence, non-maleficence, and autonomy will only be mentioned in passing if relevant to the focus on justice [15]. In the article we will explore whether the following considered judgements are consistent with PEN, PSE and PFE: CJ1: Functional conditions should be prioritized to public funding before non-functional conditions. CJ2: If patients have a preference for plastic surgery, it should be publicly funded. CJ3: If patients report suffering that can be reduced with plastic surgery it should be publicly funded. CJ4: If patients have validated suffering that can be reduced with plastic surgery it should be publicly funded. CJ5: If patient have validated suffering that can be reduced with plastic surgery and their condition is outside the range of what is statistically normal, it should be publicly funded. Results and discussion Healthcare need and the distinction between functional and non-functional conditions In publicly financed, welfare-type healthcare systems, the concept of healthcare need is essential to determining whether interventions are reimbursed [16]. Normally, status as a healthcare need is a necessary (but insufficient) criterion for reimbursement. Recent analytical developments suggest that a healthcare need should be understood as a three-part concept with the following structure [17, 18]: P has a healthcare need for intervention Y if P benefits by moving from Zcurrent level toward Zreference level through Y. P is a person or patient (whatever concept is preferred), Y is an intervention or type of intervention used within the healthcare system, and Z labels the value objective of the healthcare system. Because the type of interventions used in plastic surgery are the same as those in any surgical specialty, we assume there is no quarrel regarding Y. Considering Z, there have been numerous attempts to define the healthcare objective, which represents a consistently evolving effort [19]. However, it is notoriously difficult to determine a generally acceptable definition; therefore, we will use a more pragmatic or ‘casuistic’ approach in this article by assuming that some broad version of health is the healthcare objective. Generally, we can understand health in terms of a quality of life dimension (what is the quality of a person’s life at each point in time) and a life-length dimension (how long is the life of the person). In this context we will (almost) exclusively focus on the quality of life dimension of health, where we broadly distinguish between the physical functioning of a person (how the body works) and a person’s experienced quality of life (in this case focused on the negative side of this, suffering). This is a simplification, especially in how we use the concept of suffering, but still we believe that this is sufficient to
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