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individual wants to signal with a specific feature (i.e., a female gender with breasts) decides the normal range for this feature. Therefore, if the breast size is within the common normal range of the female gender, this will not give rise to claims to public funding; however, otherwise, it can. Opening Pandora’s box? Could the approach to this scenario open Pandora’s box for debate as to what should be publicly financed? Many patients seek private plastic surgery due to an ethnically typical nose [60, 61] or eyes [81]. However, if this ‘ethnic’ appearance is commonly represented in the population at large, it will not provide grounds for public funding. In an ethnically diverse society, where most ‘ethnic’ appearances are fairly commonly represented, most patients experiencing this condition would likely not get publicly funded plastic surgery based on application of the statistical normality criterion. Moreover, patients often approach plastic surgery with requests to look younger [82]. In both cases, the patient could arguably have an incongruence between perceived identity and appearance features, such as ethnicity and age. If gender incongruence is accepted as a healthcare need, why not other identity incongruences, such as age? Gender incongruence is an established diagnosis with professional treatment guidelines [83], and as long as age incongruence or other such incongruencies are not generally accepted in healthcare, they cannot be considered relevant healthcare needs with potential claims on healthcare resources, i.e. they would not align with PEN. Nevertheless, there has been a shift over time regarding perceptions of the differences between which conditions constitute suffering and what is viewed as a healthcare condition that should be treated within the public healthcare system. Hence, over time we might have reason to re-evalutate this. In conclusion, CJ5: “If patients have validated suffering that can be reduced with plastic surgery and their condition is outside the range of what is statistically normal, it should be publicly funded”, would seem to have some initial plausibility to constitute a hypothetical equilibrium for what should guide public funding for plastic surgery. Of course, with the proviso that it needs further testing against a broader set of principles and considerations. Study limitations and future perspectives This is the first ethical analysis performed on general principles of prioritizing plastic surgery; therefore, there is a need for further discussion of the principles and conclusions presented here. Even if the methodology of reflective equilibrium does not strive for agreement between different stakeholders per se, a part of the methodology is that the analysis and argumentation should be critically reviewed and part of a developed academic discussion before being accepted. This critical review implies reviewing the arguments and judgements for consistency and relevance. To achieve trustworthiness of the analysis, it was performed by a medical ethicist in collaboration with a plastic surgeon, and have greatly benefited from comments of a number of reviewers. Still, to further strengthen the trustworthiness of the argument, critical discussion and analysis of the suggestions we present in this article is necessary. Moreover, in this article we have only strived for a narrow reflective equilibrium, looking almost exclusively at central normative principles guiding distributive justice in healthcare. On a wider reflective equilibrium we need to broaden the scope. For example, look at psychological patterns and attitudes, feasibility of applying our approach in terms of patient, professional and public acceptance and legitimacy as well as whether consistent application of the concept of statistical normality within the field of appearance would be possible. A further complication with reflective equilibrium is what we should consider as “resting points”, i.e. more established views that we should be more resistant towards revising, be it considered judgements or principles. In this article we have taken our three principles for granted; however, they could obviously be revised and refined in different ways, enabling equilibrium with other sets of considered judgements. To our Sandman and Hansson BMC Medical Ethics (2020) 21:94 Page 11 of 14 defence, the principles we have used are wellestablished and widely accepted in many healthcare jurisdiction of welfare type, with far-ranging consequences to abandon1 . The focus on exploring general principles related to public funding of plastic surgery implies that detailed arguments need to be developed before they can be used to guide reimbursement of plastic surgery in the public healthcare system. Such developments should also include a more systematic testing of concrete cases against the principles and empirical studies on normality and appearance. Hence, in order to support the analysis in this article, further empirical studies are needed. Conclusions In exploring functional versus non-function conditions, we demonstrated the difficulty in finding a principled reason for an absolute priority of functional conditions over non-functional conditions. Nevertheless, functional conditions remain, to some extent, easier to establish objectively, and the surgical intervention has a clear causal effect on their treatment. Considering non-functional
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