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Stimulants Stimulants are being prescribed in increasing frequency for medical conditions such as attention-deficit hyperactivity disorder (ADHD) in both children and adults. The rates of use of these amphetamine and methylphenidate drugs have skyrocketed in recent years, particularly in the age–sex group of women ages 20–44. From 2001 to 2010, this group showed a spike of 264% in ADHD medication usage.1 The adult use may reflect the perceived benefit of the side effects not seen as much in the pediatric population, specifically appetite suppression. These drugs, and other closely related sympathomimetic amines have been used for weight loss and have been banned by the FDA due to a significantly increased risk of stroke in users.16 Stimulants in particular have had multiple unforeseen cardiac effects as the use of amphetamines increases cardiac rate and blood pressure, putting long-term users at increased risk for a cardiac event. Chronic use of amphetamines causes a depletion of catecholamine receptor storage, which is thought to cause reduced physiologic and sympathetic response to hypotension.17 Chronic use also leads to tolerance, which could manifest emotionally as depression and fatigue, or physiologically as a diminished pressor response to ephedrine and a diminished anesthetic requirement.17,18 Different formulas for ADHD medication could lead to increased anesthesia requirements. Drugs derived from both methylphenidate and mixed amphetamine salts have short acting and extended-release formulations. A study compared the effect of food on extended-release formulations and found that a large meal affected the drug concentration of the extended-release capsules depending on the drug. Blood amphetamine concentrations were lower when subjects had eaten breakfast, compared with blood methylphenidate concentrations, which stayed constant and were unaffected by the meal.19 This could be a factor to consider for surgery as a patient fasting preoperatively could lead to increased blood amphetamine concentrations. Mood Stabilizers Lithium is a mood stabilizer used to treat manic depression. It affects the flow of sodium through nerve and muscle cells and stabilizes manic episodes. It is known that lithium interacts with neuromuscular-blocking agents, including pancuronium and succinylcholine, and increases the duration of these drugs, making their reversibility more difficult.20 As a result, it would require that those certain anesthetic agents are reduced. constraints, given demographic changes, technological development, and citizen expectations. In publicly funded welfare-type healthcare systems (i.e., with a strong emphasis on equal access to healthcare), this implies a recurrent re-evaluation of what should be reimbursed and what should be rationed. Decisions on reimbursement can be made at 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
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