The line between cosmetic and medical treatment does not survive examination

The argument

Proponents of this position begin by asking what the word cosmetic is doing. In practice, they argue, it does not pick out a class of operations. The same procedure, performed by the same surgeon with the same result, is classified as reconstructive or cosmetic depending on how the patient came to look the way they do. A nose reshaped after it was broken is treated as medicine. The same nose, reshaped because it was always that shape, is treated as a purchase. Nothing about the surgery, the risk, the recovery or the outcome differs between the two cases. The argument is that coverage therefore tracks the history of an appearance rather than its effect on the person who has it. Proponents note that this produces decisions that are hard to defend when set beside one another: tissue removed because it causes back pain is funded while the same tissue is not funded when it causes nothing a clinician can measure, and scar revision is approved or refused according to whether the scar was made in an operating theatre or at home. Two patients who are identically affected and who would benefit identically are treated differently because of an event in the past that neither can change. Holders of the view conclude that the category is administrative rather than medical. It exists, on their reading, because a boundary was needed and causation was the easiest thing to measure, not because anyone established that appearance matters only when something happened to it. Proponents argue that a system willing to inspect this distinction will find it cannot be stated in a way that explains the decisions made under it, and that the honest response is to fund the treatment of the condition rather than the provenance of it.

Premises

Counter-arguments

Critics argue that a distinction can be rough at the edges and still be the right one. Causation is used throughout insurance and public provision because it is observable and resistant to manipulation, where reported distress is neither, and a line that is imperfect but checkable may be better than a principle that cannot be administered. They also deny that the cases are identical, since a patient restored to the state they were in before an injury is being returned to a baseline while a patient altering a lifelong feature is being given a new one. Others add that showing a boundary is arbitrary argues for moving it, not for removing it.

Rejecting the premises

[Rejecting P2] Causation is used throughout insurance and public provision because it is observable and resistant to manipulation, where reported distress is neither, so depending on it is a choice of a checkable test rather than an arbitrary one. [Rejecting P3] The cases are not identical, since a patient restored to the condition they held before an injury is returned to a baseline while a patient altering a lifelong feature is given a new one. [Rejecting C] Showing that a boundary is rough argues for moving it rather than for removing it, so the conclusion does not follow from the premises.