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normal-sized breasts; however, she previously had large breasts and wants to re-do the reconstruction to achieve larger-than-average breasts. Should society spend resources to for this breast reconstruction, despite her now having average-sized breasts? It is not unreasonable to adapt treatment to the individual circumstances and preference of a patient, and there are strong reasons to do this in circumstances when it can be done without extra expenditure. However, if such a situation requires more extensive resources, there are strong norms concerning equality against this, in that it is difficult to support taking resources from patients with greater needs (relative to a normal variation) in order to help people achieve a higher level of satisfaction than that within a normal range. Does it matter whether the procedure is related to an ability to work or a dependency on the extra resources to maintain career status? There might be exceptional cases, where people cannot continue to pursue a similar career without the extra resources. Additionally, the concept of equity implies that it is unwarranted and inconsistent to add interventions not generally performed in publicly funded systems when a warranted intervention is performed in order to achieve a more ‘perfect’ result when this is done at an opportunity cost for other patients. This might be accomplished with minimal extra resources or where there is no real opportunity cost (i.e., the resource could not have been used for other interventions). For example, adding extra operating time when the patient is under anesthesia is a resource that cannot be used to operate another patient. The same argument can be used to ration the number of corrections and revisions offered to patients considered eligible for plastic surgery in the public healthcare system [58, 76]. For example, a woman receiving one reconstructed breast associated with cancer treatment needs to accept that the natural breast will likely result in breast asymmetry, despite a volume within the ‘normal’ range [77, 78]. This suggests that it is unreasonable to spend healthcare resources to achieve a perfect result in a patient with an acceptable breast-reconstruction result as it violates both PSE and PFE. Similarly, equity also limits the influence of patient preferences when two treatments claim different resources. For example, in correcting breast asymmetry, should the patient be able to decide whether the smaller breast should be enlarged, even if it has a size within a normal range, or the bigger breast be reduced? Or even that both breasts should be changed? Such patient preferences must be balanced against other considerations, not least of which is resource constraints. Therefore, patient influence regarding exact treatment will depend on what is reasonable based on other competing conditions warranting public funding. Given this reasoning, the offer should remain consistent with what is offered to other patients and within the normal range of the population. Treatment of incongruencies between the perceived identity and appearance Would application of statistical normality as validation be at odds with the PEN, in the sense that acknowledged healthcare needs risk not receiving treatment using the concept of statistical normality? One group that does not fit into the discussion on ‘normality’ includes patients reporting an incongruence between their assigned sex and their experienced gender identity [79]. From a heteronormative perspective, these patients look perfectly ‘normal’, which is exactly the problem (normality norms cannot be applied to this patient group). For patients with a binary gender identity (having a male gender identity, despite being assigned a female sex and vice versa), there is a reference population that includes normal variations in the appearance of men and women in society. Therefore, patients with established gender incongruence and a binary identity could be offered plastic Sandman and Hansson BMC Medical Ethics (2020) 21:94 Page 10 of 14 surgery to achieve an appearance within the normal variation of men and women in society. However, this might still imply limitations in terms of intervention relative to what the patient prefers. A less clear-cut group includes patients with a nonbinary gender identity (people identifying as neither male nor female, as both male and female, as different genders at different times, or as disputing the twogender system) [80]. An example of a non-binary identity would be a biological woman who identifies as predominantly female but with strong aspects of the male gender [80]. The patient might want to keep her breasts but have smaller breasts than she has naturally, as she perceives big breasts as signaling a more female gender than her identity. Does such a patient applying an exclusive reference of self-identity have a larger claim to publicly funded breast reduction than a biological woman identifying entirely as female, but who wants smaller breasts for esthetic reasons/due to personal preferences? First, as in other cases, an objectively validated assessment of whether this causes the person suffering is needed. A personal preference for such a change is not enough in either case. Second, it has to be established whether the existing feature is within the common normal range. In the case of non-binary gender identity, this would imply that the gender type the
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