Reconstruction after injury or disease is not the same case as elective change

The argument

Proponents of this position argue that the dispute is produced by a word that covers two different things. The first is the restoration of someone to the condition they were in before something happened to them: burns, an accident, the removal of tissue in the course of treating a disease, an injury sustained at work. Proponents argue that treatment of this kind is continuous with the treatment of the original harm. The operation that saved a patient and the operation that repairs what saving them required are parts of one episode, and a system that funds the first while refusing the second has elected to treat half of an injury. The argument extends to conditions present from birth. These are not the result of an event, but proponents argue they share the feature that matters, which is that the person did not bring the condition about and could not have avoided it. On this reading the criterion is not whether an operation alters appearance, since all of these do, but whether the appearance being altered is the result of something unchosen that medicine would otherwise have been addressing. Holders of the view argue that this criterion does real work, because it also excludes. A patient seeking to change a feature that is simply theirs, which no injury produced and no disease removed, is asking for something different in kind, however strongly they want it and however sympathetic the wish. Proponents accept that this leaves them defending a boundary rather than a principle of universal access, and argue that the boundary is defensible in a way the two general answers are not: it explains why reconstruction is funded without committing a system to funding everything, and it rests on a distinction that can be stated and applied.

Premises

Counter-arguments

Critics on one side argue that the criterion still rests on history rather than effect, and so inherits the objection it was meant to answer: two patients equally affected are funded differently because of how they came to be that way. Critics on the other argue that it is too generous, since conditions present from birth are not injuries and extending coverage to them abandons the restoration principle that gave the position its shape. Both note that the hard cases are precisely the ones the test cannot sort, including appearance altered gradually by illness, by ageing, or by treatment whose effects were foreseen and accepted at the time.

Rejecting the premises

[Rejecting P1] The criterion still rests on how an appearance arose rather than on its present effect, so it inherits the objection it was meant to answer. [Rejecting P2] Conditions present from birth are not injuries and nothing was disrupted, so including them abandons the restoration principle that gives the position its shape. [Rejecting C] Appearance altered gradually by illness, by ageing or by treatment whose effects were foreseen cannot be sorted by the test, which leaves the hard cases unresolved.