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Of course I do understand that what follows is a lot more complicated, but I think that in general medicine should always be driven by primum non nocere - first do no harm principle and I would be much more strict in enforcing this. So for instance transhumanist things like most forms of esthetic medicine such as breast implants, trans surgeries, contraception pills, sterilizations, euthanasia, abortion and other similar or procedures or drugs would be considered outside of core publicly funded medicine. It could still be provided but under different scope let's say akin to getting tattoo or going to nail saloon and thus it should be automatically clear to the customer that the primary goal is unrelated to certain standard of this no-harm principle and that he or she should accept the risks as well as costs associated with it.
As for the part where people do not follow the medical plan or even actively sabotage it, which then requires even more resources from the system, I think having a system of deductibles like let's say in Singapore can partially resolve the problem. So the principle is that state pays for your medical bills because it is a prosocial thing to do in order to have healthy population but only up to the point. A level up from that is to involve immediate family so for instance part of the costs will be coming from their savings so that the immediate family (children, spouse, parents) has incentive to pressure that person to do something about themselves or they will be at least partially held accountable.
I've seen a fair amount of online complaints about "I don't want kids, I'm sure I don't want kids, I want to be sterilised but the doctors won't do it because I'm too young and might want kids later, I'm sure I don't want kids".
I think the solution there is to take away the right to sue in case of change of mind: you understood this procedure would make you sterile, you requested it because you wanted to be sterile, you signed the agreement that you understood this, now five years later when you can't get your boyfriend to marry you because he wants kids, you can't come back and sue us for giving you what you wanted.
Also protection around minors: yes, I'm sure your child is a very mature and intelligent 12 year old and is not being pressured by you to go for this procedure, but I'm not doing it until they're 18. Be that anything from plastic surgery to hormones, even with threats of "but my child will commit suicide if you don't do this!"
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Do you think physicians have a role in executions? Our stance is for the most part no (because do no harm), but I do think about the Solus principle - "had to be me, someone else might have gotten it wrong."
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