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CONCLUSION Use of psychoactive drugs is endemic in the US population. Plastic surgery patients as a subgroup are even more likely to be on psychoactive medications, with 33.6% cosmetic patients versus 46.3% reconstructive patients. This study shows that plastic surgery patients are more likely to be on psychoactive medications than the general population. Significantly more reconstructive patients (46.3%) took psychoactive medications than did cosmetic patients (33.6%), and the cosmetic patient is more likely to be on a stimulant than and the reconstructive patient on an antidepressant. However, by the end of their treatment, reconstruction patients are more likely to be on medications than cosmetic surgery patients, which have implications for staged surgery. A patient’s drug history forms need to be appropriately updated as care progresses as the patient may now be on a psychoactive agent when in surgical care. Modern plastic surgery training with its focus on procedures and products under emphasizes the medical and psychological issues. Training in psychiatry and psychoactive drugs should be incorporated as more of our patients present on them. 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 argue our point in this article [19]. When analyzing plastic surgery, we evaluate how comparable problems are handled elsewhere in the healthcare system, with the intention of arriving at consistency and identifying borderline cases. It is generally assumed that the objective of healthcare is not necessarily ideal or optimal health but rather acceptable health, given the health level of the society in question when operating under scarce resources. Therefore, it is assumed that Zcurrent level < Zreference level, implying that there could be levels of health above the reference level, and that different conditions can be equivalent to the reference level of health. Looking at that proposed definition, we find that there is both, what we might call a severity component of healthcare need, i.e. how far the patient is from the Zreference level in the current situation and to what extent the healthcare intervention Y can bring her closer to Zreference level, what we might call the effectiveness of treatment. Hence, our principle PSE, will have two aspects to consider, a severity and an effectiveness aspect. Functional and non-functional conditions Let us start by analyzing CJ1 (that functional conditions should be prioritized before non-fuctional conditions to public funding). The distinction between a functional and non-functional condition is common in plastic surgery, voicing the distinction between esthetic and reconstructive surgery from the AMA [11]. This distinction is far from clear, but in this article we will use it in the following way (drawing on the above conceptualization of health). A functional condition is one involving impairment of a physical function, where impairment will imply functioning outside of what is statistically normal for the population the patient belongs to (see below). A non-functional condition, by distinction, does not involve impairment of a physical function. Generally, in this article, non-functional conditions will imply a condition related to the appearance of the person. In some cases, as will be shown below, non-functional conditions Sandman and Hansson BMC Medical Ethics (2020) 21:94 Page 3 of 14 might indirectly result in physical dysfunction, e.g. when patients abstain from healthcare interventions since it would affect their appearance negatively or when it results in excessive weight loss or training. However, at this point we hope the distinction between physical dysfunction and problems related to appearance is clear enough for the analysis. Following this, it seems CJ1 aligns with PEN, i.e. functional conditions are indeed healthcare needs. The assumption is that a physical functional condition lowers health to a greater degree and is better suited for surgical treatment than non-functional conditions resulting from the experienced appearance of the patient [4, 20]. In other words that CJ1 aligns with PSE. Therefore, a functional condition warrants publicly funded plastic surgery to a greater extent than a non-functional condition. For example, qualifying for abdominoplasty requires more than the presence of a significant amount of excess skin and the associated suffering. The problem needs to exist in combination with a functional condition, such as eczema, infections, or micturition difficulties [3, 21]. Moreover, healthcare systems might perform breast reductions to alleviate back symptoms, although normally not breast augmentations, even when small breasts might cause some degree of suffering [3, 4, 22]. Experiencing a functional condition can obviously give rise to suffering, but it can also be a problem, despite patient experience (e.g., increased risk of premature death, a risk of future suffering). Additionally, the condition might introduce an objectively observable functional limitation, in which case it might be easier to objectively establish a healthcare need. For example, reducing breast size will relieve back strain, or abdominoplasty will remove the environment where eczema and infections thrive. Such reasoning makes it easier for both the patient and surgeon to classify the operation as medically warranted and not purely an esthetic intervention [23]. To define healthcare needs in terms of objectively quantifiable indications also provides the patient and surgeon with a feeling that the procedures are legitimate and offered in a consistent way according to the requirements of equity [23]. However, such a statement needs qualification. First, we need a standard for when a functional variation qualifies as a functional condition. Generally, finding such a standard requires identifying a range of variations outside of which the risk of a certain negative outcome is high enough. Another way to express this is in terms of statistical normality according to Boorse [24]. If an organ is functioning inside a range of what is statistically normal in a population, there is no problem; however, if there is a malfunction in relation to this range, there is a problem. Therefore, we need to define this range in order to identify when a healthcare intervention is warranted.
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