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concept that has been used to suppress groups that deviate from what is found as good or right in society [23]. Therefore, ‘normal’, on this understanding, is also considered ‘good’ (or ‘morally commendable’ or ‘the way things should be’), and the entire approach of norm criticism builds upon an idea concerning a problematic and restrictive value-laden characteristic of normality (e.g., in terms of hetero-normativity) [23]. The idea of what is normal appearance changes as a consequence of media and internet exposure to people who have had plastic surgery [7, 8], and patients pursuing private esthetic surgery now motivate their choice with a wish to be ‘normal’ [52]. The exposure to plastic surgery also increases patient expectations on what can be achieved by surgery [7, 8], which affects the perceived need of plastic surgery. Moreover, a positive experience of one plastic surgical procedure can trigger a perceived need for more plastic surgery to further improve body image satisfaction [53]. In healthcare, such a normatively laden view on normality should be avoided. Expressed in another way, normative normality is not consistent with accepting principles of equality and autonomy accepted at large in a democratic, liberal society and should therefore not be accepted within the healthcare system. Normality as etiology Another approach to normality that is potentially less problematic would be to evaluate the etiology of the condition. The following examples of etiologies appear relevant to public funding: malformations or tissue defects following cancer or trauma, but also conditions caused by medical treatment. When a patient has a crooked nose following a trauma, rhinoplasty is generally offered [54], whereas a congenitally crooked nose is considered a ‘normal anatomical variant’ and, therefore, not treated in the public healthcare system. When HIV treatment leads to lipodystrophy, with resulting suffering and social dysfunction, treatment with soft-tissue fillers, grafts, or lipofilling is usually offered [25, 55], whereas age-related facial grooves are not treated. Women with natural breast asymmetry need to meet rigorous criteria to be operated in the public sector [22, 56], whereas women who have had breast cancer are granted a contralateral procedure for symmetrization as a rule [57]. Moreover, in patients considered eligible for plastic surgery in the public healthcare system, corrections and revisions are generously performed upon patient request [58]. Patients with cleft lip and palate (CLP) are generally offered rhinoplasty to improve esthetics and ‘psychosocial rehabilitation’ [59], whereas unattractive noses without underlying malformation are not operated in the public healthcare system [60, 61]. What is the common denominator here? For the latter examples, if the healthcare system causes a condition (through treatment for some other condition), they have a specific responsibility to treat that condition. This does not cover the malformations resulting from cancer or trauma. A more general idea would be that conditions caused by some form of human choice or intervention would motivate funding; however, this neither covers malformations following cancer nor trauma. Although our goal here is not to explore all potential suggestions on the definitions of such etiologies, this discussion acknowledges the ambiguity in how this would be accomplished. Why should the etiology of the condition matter? One idea is that a person adapts to his/her congenital appearance, whereas a change in appearance is more difficult to handle and entails more suffering. This would be a reason to operate a patient with a crooked nose following a Sandman and Hansson BMC Medical Ethics (2020) 21:94 Page 7 of 14 trauma [54] but not the patient with a congenitally crooked nose. However, patients seeking plastic surgery for congenital conditions have not adapted to them but still suffer and are distressed (given the above requirement concerning objectively measurable suffering). If two different patients have the same appearance and similar suffering as a result, it is difficult to identify a convincing reason why the etiology of the condition would matter. In other words, normality as etiology does not align with PFE. If a condition is the result of negligence on behalf of the healthcare professional(s), it can be argued that there is a moral responsibility to re-operate. However, if it is not the result of negligence but rather the expected outcome of a treatment indicated for the patient and which the patient had accepted based on information concerning expected iatrogenic conditions, it is difficult to assign a specific moral reason to prioritize such conditions before conditions with other etiologies. Consider the following example: Woman A suffering from breast cancer has undergone breast-conserving surgery, resulting in breast malformation after the wounds have healed. Another woman, B, is born with a somewhat worse form of breast malformation. Both are experiencing suffering an as a result of these malformations; however, the woman born with her condition has slightly more suffering due to the more pronounced malformation. It is difficult to find a compelling reason for why woman A, having undergone breast cancer treatment, should be prioritized over woman B if B’s malformation is outside the normal range
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