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Additionally, nonsteroidal anti-inflammatory drugs combined with lithium can cause toxic plasma levels as they reduce the excretion of lithium by the kidneys.21 It is the general anesthesia recommendation that lithium use is discontinued at least 24 hours before surgery. In our practice, the incidence of psychoactive drug use in our female cosmetic patients is 33.6% and 46.3% in female breast reconstruction patients. Our data exhibit a high rate of psychoactive drug use in comparison with the general patient population. The number of American women taking psychoactive drugs has increased from 21% in 2001 to 26% in 2010.1 Moreover, a study by the CDC showed that women are 2.5 times as likely to take antidepressants as men, with the largest age–sex group being women aged 40–59.4 Although antidepressant use is on the rise, one study evaluating the prevalence of antidepressant use among breast cancer patients showed that its use has increased from <1% before 1993 to 1.8% from 1993 to 1996, to 8% from 1997 to 2002; clearly these data are out of touch with our findings in 2016.10,22 In our practice, the percent use of antidepressants in the reconstructive patients is statistically significantly higher than our cosmetic surgery patients. The high incidence in breast cancer patients could be a result of an increased prescription of antidepressants over time of treatment as depression associates with the disease. Out of the population of breast cancer patients at our practice, 24.8% are taking antidepressants. However, we are unable to identify how many patients were on these drugs before their diagnosis of breast cancers as they presented to our practice only after their diagnosis. Because breast cancer patients may change medications often and undergo repeated surgery, they should update their medical history frequently. As the incidence of Axis I disorders (such as schizophrenia) is unlikely to have changed in recent times, antipsychotics are expected to be the most constant and smallest group. It is the other categories that are in the ascension. Notably, stimulant use has increased among our patients in the last few years. Cosmetic surgery patients are 3 times more likely to be taking amphetamine salts than reconstructive patients. These are typically younger patients that are representative of the spike in ADHD medication prescription. We have found from collecting data on psychotropic drug use that a patient’s medical history alone will often not disclose a patient’s entire medical or drug history. Surescripts, an online portal that lists the medications a patient has filled from their pharmacies over a period of 4 years, has identified underlying medical problems, including psychological or anxiety issues, that patients have not disclosed. Recent studies in psychological issues among plastic surgery patients found 70% of cosmetic patients had Axis II disorders, and 19.5% had Axis I disorders, based on the diagnostic criteria from the Diagnostic and Statistical Manual of Mental Disorders, third edition, revised [DSM-III-R].23 These results align with previous studies throughout the 1960s, which employed clinical interviews to analyze psychiatric disturbance.23 One could have anticipated that cosmetic surgery patients use more psychoactive drugs than the general population. However, one may not have anticipated that the psychoactive drug usage of reconstructive patients exceeds both the usage of the general population and the usage of cosmetic surgery patients. 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 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
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