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[38]. Therefore, it is not necessarily true that the patient with the most prominent experienced pre-operative dysfunction should be treated with plastic surgery. Similarly, there is no connection between psychosocial conditions and the severity of disfigurement [30]. The previous study comparing patients seeking plastic surgery for functional reasons with those seeking care for nonfunctional reasons concluded that even if those seeking care for non-functional reasons exhibit a greater level of distress and problems relative to those seeking care for functional reasons, this still might not be clinically significant enough to warrant publicly funded plastic surgery [28]. Therefore, even if plastic surgery for functional conditions is not always more effective than that for non-functional conditions, the treatment effect might be more easily established from an objective standpoint. Once again, CJ1 does not necessarily align with PSE in all cases as to the effectiveness aspect. Are functional conditions generally prioritized over nonfunctional conditions in the healthcare system? Functional conditions are not necessarily prioritized over non-functional conditions in the healthcare system to the extent that there exist available and effective healthcare interventions. The dominant approach to classifying disabilities, the International Classification of Functioning, Disabilities, and Health covers both physiological symptoms, practical activities, and social aspects without giving precedence to any one of these aspects over the others [39]. In the healthcare system, there are examples where patients are provided with surgical interventions on psychosocial indications or due to experienced suffering. For example, requests for elective caesarean section due to a fear of childbirth are generally granted if the wish persists despite adequate therapy and psychiatric treatment, with the decision often motivated by the thought that not granting a caesarean section for these patients might lead to depression and post-traumatic symptoms [40]. However, there are examples elsewhere in the healthcare system where a desire for surgery based on anxiety and psychosocial conditions is denied. For example, women are generally not offered prophylactic mastectomies if they do not have a verified significant higher risk of breast cancer, such as a known mutation, even if they have a fear of breast cancer that affects their daily life [41]. In such cases, surgery is not considered the best treatment option, as prophylactic mastectomies, in cases where there is not an increased risk for malignancy, do not affect the incidence of cancer or life expectancy [42], despite the operation potentially decreasing patient anxiety. Similarly, removal of benign skin lesions is generally not offered [3], even if the patient is worried about malignancy. So, it seems that CJ1 might also violate PFE. Conclusions concerning functional versus non-functional conditions Despite the lack of consistency in how non-functional versus functional conditions are treated within the healthcare system, it is difficult to find a principled reason for an absolute priority of functional conditions Sandman and Hansson BMC Medical Ethics (2020) 21:94 Page 5 of 14 taking precedence over non-functional conditions. Currently, both types of conditions are treated according to condition severity, alternative treatments, and treatment effectiveness. Generally, the concept of health implemented in the healthcare system do not support a sharp distinction between physical functionality and experienced suffering. Hence, CJ1 are not in equilibrium with our three principles PEN, PSE and PFE. Nevertheless, functional conditions are somewhat easier to establish objectively, and the associated surgical intervention has a clear causal effect on treating the functional condition. It is also possible that a larger number of functional conditions exist with a corresponding high degree of severity relative to nonfunctional conditions. Non-functional appearance-related conditions Having established the difficulty in normatively supporting a strict priority of functional over non-functional conditions (i.e. CJ1), we now focus on how to assess non-functional appearance-related conditions. Distinct from functional conditions, non-functional conditions are exclusively related to the experience and/or preference of the patient. First, a short note on the distinction between subjective experiences of suffering and preferences related to plastic surgery and analysis of CJ2, i.e., that it should be enough to have a preference for plastic surgery from the patient to receive public funding. Someone might have a preference for plastic surgery without this being associated with suffering (e.g., they simply prefer to look different). If there are no other health conditions related to the condition (e.g., functional conditions), there will be no Z-gap (according to the definition of health above) and thus no healthcare need. Hence CJ2, does not align with PEN and our conclusion is therefore that patient preference is an insufficient criterion for publicly funded plastic surgery. Establishment of a healthcare need requires at least some degree of suffering associated with the condition on which the patient is focused. The same physical feature can be associated with a suffering strong enough to result in a preference for its alteration in one
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