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Breast reduction to allow a patient to live with slightly smaller breasts that decrease back strain might not represent a large enough functional problem. Similarly, harboring excess skin with a small risk of eczema or infection might not be a large enough functional problem. Nevertheless, if there is a functional condition, but the patient does not experience or value the consequences of this as a problem, there is no healthcare need. Note that this does not exclusively concern what is experienced as a problem in the present. We normally do not experience risks, but we might still value the potential outcome of a risk as a problem. However, if there is a functional condition and the patient does not find either the present or the potential future outcomes as problematic (even in principle), it would be strange to claim the existence of a healthcare need. Plastic surgery is needed to avoid premature death associated with (for example) large burn wounds and extensive tissue defects after removal of advanced tumors, such as head-and-neck, colorectal, and gynecologic cancers, and after trauma. In these cases, avoiding premature death is important to the extent that a patient wants to continue living (under the given circumstances). Eczema, infections, and back pain give rise to suffering. In some instances, functional conditions might lead to worse problems requiring more extensive interventions if not addressed. For example, failure to perform surgery on a scar contracture causing impeded physical function, such as restricted arm movement, could potentially eliminate the possibility to rehabilitate joints, thereby negatively affecting QoL. Therefore, patient experience and values need to be accounted for while assessing the existence of a healthcare need. This illustrates the difficulty in drawing a clear distinction between functional and other conditions, given their movement on the same scale. Hence, in effect, it is not obvious that functional conditions always better align with PEN than non-functional conditions, and aspects central to non-functional conditions are also part and parcel of functional conditions. Are functional conditions more serious than non-functional conditions? In some cases, functional conditions are obviously highly serious, as they can potentially result in unwanted premature death, and a high level of suffering. In such cases, reimbursement of plastic surgery is never an issue. The risk of non-functional conditions resulting in premature death, or extensive suffering, should however not be underestimated. Some patients with human immunodeficiency virus (HIV) stop taking their anti-retroviral drugs and risk their lives in order to avoid the esthetic implications of the medication [25]. Moreover, other patients commit suicide due to suffering following Sandman and Hansson BMC Medical Ethics (2020) 21:94 Page 4 of 14 perceived appearance conditions [26]. Empirical data suggest that esthetic conditions or an altered body image are related to psychosocial or even psychiatric conditions giving rise to suffering, and that people do suffer from experienced esthetic abnormalities and imperfections that can impede daily life [27–31]. A previous study compared patients seeking plastic surgery in the public healthcare system for functional reasons with those seeking care for esthetic reasons, finding that those seeking care for purely esthetic reasons were more distressed than population norms. Moreover, the esthetic group displayed worse social function than healthy people, whereas the functional group exhibited social function comparable to that of healthy people [28]. Furthermore, it was suggested that people receiving certain types of esthetic plastic surgery more frequently experience mental health conditions, and suffering in terms of anxiety and depression, as compared with the general population [31, 32]. These findings suggest that it is not obvious that functional conditions are always more severe than non-functional conditions and so CJ1 does not necessarily align with PSE as to the severity aspect. Is plastic surgery a more effective treatment for functional conditions than for non-functional conditions? Plastic surgery has a more directly measurable impact on functional conditions than non-functional conditions. For example, reductions in breast size reduce back strain according to the laws of physics, and if excess skin is removed, this hinders the environment for bacterial infection. The effect of plastic surgery on non-functional conditions is more indirect and, therefore, more difficult to quantify. Numerous studies show that esthetic plastic surgery improves QoL (or reduces suffering in our terminology) [33], although there is little evidence of longterm effects on psychosocial functioning and QoL and, by extension, the true benefit of the treatment [33–35]. Therefore, it remains unclear whether non-functional conditions related to appearance are best treated with plastic surgery or some other health intervention. Moreover, the relationship between suffering and plastic surgery is complex. Studies revealed that patients with mild-to-moderate distress might benefit more from surgery than those with a higher level of distress [36, 37]. In some cases, a high level of distress due to appearance conditions could be an indication of body dysmorphic disorder, in which case surgery is contra-indicated
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