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resources, consider the following situation: Patient A suffers from what she considers breast asymmetry, which is within a range common among women (40% of women have asymmetry within this range), most of whom do not experience suffering that results in their seeking healthcare. Patient B has the same level of suffering from what she considers breast asymmetry, which is extremely uncommon (< 0.5% of women have asymmetry within this range) and manifests as a large difference between the left and right breasts. If both patients cannot receive publicly financed plastic surgery, how should such a choice be made? The two patients experience the same suffering from asymmetry; therefore, the amount of suffering per se is not grounds for distinguishing the conditions. The only difference is the statistical normality of the asymmetry, which is accounted for when assessing functional conditions. In these cases, functional disabilities appear to be a relevant parallel example. Even if two patients with a mobility condition experience the same degree of suffering, we would find greater reason to prioritize the patient with the greater mobility impairment. The strongest reason for this is equality. If people appear to be objectively on the same level, equality does not support using common resources to improve their situation further, especially if there are other people with worse conditions in the population. A reference level for equality is needed, and this is explicitly or implicitly represented by the general level of health of the normal population in terms of health-related QoL and life expectancy [72]. Another reason is that a publicly funded healthcare system needs to have democratic legitimacy, in the sense that the population should find the use of healthcare resources largely acceptable. It is unlikely that people would agree to spend resources on what is within a common variation as opposed to other less common maladies, especially if this common variation appears accepted by most people with the variation (i.e., Patient A). This is illustrated by the strong reactions from taxpayer alliances and the public when the matter is discussed [73, 74]. However, it can be argued that suffering rather than physical features should be taken into account. Consider the following two patients: Patient B suffers from what she considers to be breast asymmetry that is highly uncommon (< 0.5% of women have asymmetry within this range), with a large difference between the left and right breasts. Patient C reports a higher degree of suffering according to validated objective measurements from what she considers to be breast asymmetry, which is within a range common among women (40% of women have asymmetry within this range), most of whom do not experience suffering that results in their seeking healthcare. In this situation, it is important to note that both patients are suffering from their condition and have a preference for plastic surgery; however, once again, we have to prioritize. There can be many explanations for a difference in suffering (e.g., people respond differently to what happens to them due to previous experiences and psychological robustness), as well as how people adapt to their present condition(s) [75]. Why should patient C not be prioritized in this case, given her greater suffering? It is not because her suffering is not real; this was validated as being greater than that of patient B. It is rather that her suffering does not appear reasonable according to the associated physical feature. There is a complex relationship between distress level and whether plastic surgery will improve the condition [36, 37]; therefore, distress level alone does not appear to be a sufficient measurement to establish whether publicly funded plastic surgery is indicated. In such a case, if both the normal range for the physical feature Sandman and Hansson BMC Medical Ethics (2020) 21:94 Page 9 of 14 and the suffering are considered together, patient C should receive a lower priority than patient B. Should society spend public resources on supporting alterations of physical features within the common range of the population? Consider the following example: A man is suffering greatly, because he is unable to climb the Himalayas due to low oxygen consumption; however, his oxygen consumption is within the range of most people (perhaps a bit on the lower end) in his age category. There is currently a treatment that would improve his oxygen consumption above the level of most people, thereby enabling him to climb the Himalayas. Should this be a priority for spending scarce public resources? The answer appears to clearly be ‘no’. Even if he is experiencing great but idiosyncratic suffering, it goes beyond what scarce resources should be used for as long as there are greater needs in the population. On the PFE, we should therefore not reason along these lines in plastic surgery. One objection to this concerns person-centered care. What if this man used to be a mountaineer with a high oxygen-consumption rate that was lost due to a stroke? Should he not qualify for treatment to a greater degree than other patients with the same medical condition? This concept can be applied to plastic surgical procedures. For example, a woman diagnosed with bilateral breast cancer received an adequate breast reconstruction resulting in symmetrical
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