OT: J. of Can Dental Assoc - The Science and Ethics of Water Fluoridation

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http://www.cda-adc.ca/jcda/vol-67/issue-10/578.html

The Science and Ethics of Water Fluoridation

• Cohen, BA, MA, PhD •

• Locker, BDS, PhD •

© J Can Dent Assoc 2001; 67(10):578-80

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A statement concerning the ethics of water fluoridation was published in a

recent issue of the Journal of the Canadian Dental Association.1 The

arguments presented in that paper did not constitute what we would consider

a complete and systematic account of the scientific and moral issues

involved. It is our contention that water fluoridation, by the very nature

of the way it is administered, engenders a number of moral dilemmas that do

not admit to any easy solution. In this paper, we attempt to elucidate the

particular problems posed by this public health initiative, according to

the principles of bioethics.

The Role of Bioethics

Whether or not water fluoridation reduces dental caries in child

populations has been subject to considerable debate.2,3 This debate is

scientific rather than moral in character and revolves around the validity

of the evidence concerning the benefits of adding fluoride to community

water supplies. However, even if it were universally accepted that water

fluoridation is beneficial and the scientific evidence incontrovertible, it

would still have a moral dimension. This moral status arises in the

application of water fluoridation in health care policy and public health

practice. Attitudes toward public health initiatives are of necessity

shaped by values. Bioethics is the study of the moral, social and political

problems that arise from biology and the life sciences, and that involve

human well-being.4 Of particular relevance are the core values of autonomy,

beneficence and truthfulness.

Beneficence and Autonomy

Beneficence denotes the practice of good deeds and signifies an obligation

to benefit others or seek their good. How this principle is put into

practice depends on whose notion of good is applied. Health policy-makers

and professionals, in advocating for the addition of fluoride to drinking

water, are making moral decisions about the well-being of individuals and

applying their own notions of good. If beneficent acts are to benefit the

recipients of the actions, the basis for the goodness of the actions must

lie in the values or preferences of autonomous, self-determining

individuals. In practice, however, beneficent acts such as water

fluoridation tend to be in conflict with autonomy. Since it is effectively

impossible for individuals to opt out, fluoridation takes away the freedom

to choose.

Advocates of water fluoridation argue that the benefits accruing to society

through reductions in dental caries outweigh any harm to individual

autonomy. Defenders of autonomy argue that fluoride is available from many

sources, and so its benefits can be realized without violating the

principle of autonomy. However, this presumes that everyone in society can

access these alternative sources. The most vulnerable in society, it is

countered, would surely miss out on the benefits of fluoride.1

Therefore, considering the benefit that accrues to disadvantaged groups in

society, advocates of fluoridation contend that water supplies should be

fluoridated on the grounds that everyone, regardless of socioeconomic

status, can benefit. The claim here is that water fluoridation promotes

social equity. This solution still leaves the conflict of beneficence and

autonomy unresolved. In fact, there appears to be no escape from this

conflict of values, which would exist even if water fluoridation involved

benefits and no risks. However, water fluoridation does involve risks, in

the form of increases in the prevalence and severity of dental fluorosis.

Moreover, as Coggon and 5 indicate, those most likely to benefit from

water fluoridation are not necessarily those placed at most risk. This

complicates considerably any attempt to balance beneficence and autonomy.

Advocates of water fluoridation, in seeking to strike a balance between

competing values, are attempting to reconcile irreconcilables: the demands

of moral autonomy cannot be made compatible with what could be regarded as

the involuntary medication of populations. This situation gives rise to the

question of which values concerning the conflict between beneficence and

autonomy should inform decision making with respect to water fluoridation:

those of health professionals or those of the community?

Truthfulness

An assessment of the ethics of water fluoridation must also take into

account the moral issues surrounding scientific inquiry in order for health

professionals to be justified in advising or compelling others how to act.

This aspect pertains to the principle of truthfulness, whereby health

professionals are obligated to tell their patients the truth,6 for one

cannot influence the way others act without first being justified in one’s

own beliefs.

The conventional view is that policy-makers are presented with a clear

moral choice when weighing the benefits and harms associated with water

fluoridation. Historically this may have been the case. The original

community trials of water fluoridation indicated a substantial effect.7,8

However, over the past 25 years there has been a marked reduction in rates

of dental caries among children, such that the benefits of water

fluoridation are no longer so clear. Although current studies indicate that

water fluoridation continues to be beneficial, recent reviews have shown

that the quality of the evidence provided by these studies is poor.9-11 In

addition, studies that are more methodologically sound indicate that

differences in rates of dental decay between optimally fluoridated and

nonfluoridated child populations are small in absolute terms.12,13 Canadian

studies of fluoridated and nonfluoridated communities provide little

systematic evidence regarding the benefits to children of water

fluoridation.14-17 Moreover, studies of the benefits to adults are largely

absent,9 and there is little evidence that water fluoridation has reduced

social inequalities in dental health.10

Truthfulness entails a proper appraisal of the benefits and risks.

Currently, the benefits of water fluoridation are exaggerated by the use of

misleading measures of effect such as percent reductions. The risks are

minimized by the characterization of dental fluorosis as a “cosmetic”

problem. Yet a study of the psychosocial impact of fluorosis found that “10

to 17 year olds were able to recognize very mild and mild fluorosis and

register changes in satisfaction with the colour and appearance of the

teeth.”18 The investigators also stated, “The most dramatic finding was

that the strength of association of [fluorosis] score with

psycho-behavioural impact was similar to that of overcrowding and overbite,

both considered key occlusal traits driving the demand for orthodontic

care.” In the absence of a full account of benefits and risks, communities

cannot make a properly informed decision whether or not to fluoridate, and

if so at what level, on the basis of their own values regarding the balance

of benefits and risks.

In the absence of comprehensive, high-quality evidence with respect to the

benefits and risks of water fluoridation, the moral status of advocacy for

this practice is, at best, indeterminate, and could perhaps be considered

immoral.

Conclusion

These scientific and moral issues must be addressed and resolved if policy

and practice with respect to water fluoridation are to be considered

ethically sound. Yet it is not clear that this work can be accomplished

satisfactorily. The conventional view that the ethical dilemmas posed by

water fluoridation can be resolved by balancing the benefits and harms

actually begs the question, for it presumes that such a balance can be

achieved. The preceding arguments indicate that this view needs to be

replaced by a moral account showing an appreciation for the ineradicability

of the conflict of values that water fluoridation engenders. They also

raise the question of whose values should take precedence when decisions

regarding water fluoridation are being made.

Ethically, it cannot be argued that past benefits, by themselves, justify

continuing the practice of fluoridation. This position presumes the

constancy of the environment in which policy decisions are made. Questions

of public health policy are relative, not absolute, and different stages of

human progress not only will have, but ought to have, different needs and

different means of meeting those needs. Standards regarding the optimal

level of fluoride in the water supply were developed on the basis of

epidemiological data collected more than 50 years ago. There is a need for

new guidelines for water fluoridation that are based on sound, up-to-date

science and sound ethics. In this context, we would argue that sound ethics

presupposes sound science.

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Dr. Cohen has a PhD in political and moral philosophy from the University

of Toronto. He is currently enrolled in the dental undergraduate program at

the University of Toronto.

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References

1. McNally M, Downie J. The ethics of water fluoridation. J Can Dent Assoc

2000; 66(11):592-3.

2. Diesendorf M, Colquhoun J, Spittle BJ, Everingham DN, Clutterbuck FW.

New evidence on fluoridation. Australian N Z J Public Health 1997;

21(2):187-90.

3. Spencer AJ. New, or biased, evidence on water fluoridation? Australian N

Z J Public Health 1998; 22(1):149-54.

4. Potter VR. Bioethics: Bridge to the Future. Englewood Cliffs: Prentice

Hall, 1971.

5. Coggon D, C. Fluoridation of water supplies: Debate on ethics

must be informed by sound science. BMJ 1999; 319(7205):269-70.

6. Higgs R. On telling patients the truth. In: Lockwood M, editor. Moral

dilemmas in modern medicine. Oxford: Oxford University Press; 1985.

7. Burt B, Eklund S. Dentistry, dental practice and the community. 5th ed.

Philadelphia: WB Saunders Company; 1999.

8. DW, Banting DW. Water fluoridation: current effectiveness and

dental fluorosis. Community Dent Oral Epidemiol 1994; 22(3):153-8.

9. Locker D. Benefits and risks of water fluoridation. University of

Toronto, Community Dental Health Services Research Unit; 1999.

10. McDonah M, Whiting P, Bradley M, J. A systematic review of

public water fluoridation. University of York: NHS Centre for Reviews and

Dissemination; 2000.

11. Hawkins RJ, Leake JL, Adegbembo AO. Water fluoridation and the

prevention of dental caries. J Can Dent Assoc 2000; 66(11):620-3.

12. Slade GD, Davies MJ, Spencer JA, JF. Association between

exposure to fluoridated drinking water and dental caries experience among

children in two Australian states. J Public Health Dent 1995; 55(4):218-28.

13. Heller KE, Eklund SA, Burt BA. Dental caries and dental fluorosis at

varying water fluoride concentrations. J Public Health Dent 1997;

57(3):136-43.

14. Clovis J, Hargreaves JA, GW. Caries prevalence and length of

residency in fluoridated and non-fluoridated communities. Caries Res 1988;

22(5):311-5.

15. Ismail AI, Brodeur JM, Kavanagh M, Boisclair G, Tessier C, Picotte L.

Prevalence of dental caries and dental fluorosis in students 11-17 years of

age, in fluoridated and non-fluoridated cities in Quebec. Caries Res 1990;

24(4):290-7.

16. Ismail AI, Shoveller J, Langille D, MacInnis WA, McNally M. Should the

drinking water of Truro, Nova Scotia be fluoridated? Water fluoridation in

the 1990s. Community Dent Oral Epidemiol 1993; 21(3):118-25.

17. DC, Hann HJ, on MF, Berkovitz J. Effects of lifelong

consumption of fluoridated water or use of fluoride supplements on dental

caries prevalence. Community Dent Oral Epidemiol 1995; 23(1):20-4.

18. Spencer AJ, Slade GD, Davies M. Water fluoridation in Australia.

Community Dent Health 1996; 13(Suppl 2):27-37.

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http://www.cda-adc.ca/jcda/vol-67/issue-10/580.html

The Science and Ethics of Water Fluoridation — A Response

• McNally, MSc, DDS •

• Jocelyn Downie, MA, MLitt, LLM, SJD •

© J Can Dent Assoc 2001; 67(10):580

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Although Drs. Cohen and Locker have used a different philosophical approach

to address the issue of the ethics of water fluoridation, many of their

observations are similar to our own. We agree that this is an important

policy issue for organized dentistry; we agree that the current scientific

literature is weak and that more high-quality scientific research needs to

be carried out (although we would add that such research should include

economic and socioeconomic parameters); and we agree that the moral

dimensions of public policy issues are complex and not easily resolvable.

Their conclusion that there is an unresolved conflict between beneficence

and autonomy is accurate. Simply put, a considered good in the eyes of one

member of society may be an infringement of the rights and freedoms of

another. Value conflicts speak to the very nature of bioethics.

So what do we do? Right now in Canada there are communities with

fluoridated water supplies and those without. Canadian society looks to the

Canadian Dental Association (CDA) and the profession in general for

guidance and leadership about issues that require their expert knowledge

and interpretation. Cohen and Locker seem to suggest that the CDA should

not take a position in favour of fluoridation. They claim that “the moral

status of advocacy for this practice is, at best, indeterminate, and could

perhaps even be considered immoral.” We take exception to this claim. Even

in the face of indeterminate evidence and conflicting abstract principles

and values, the profession cannot avoid taking a position, especially given

the fact that water fluoridation has traditionally been supported as an

important public health measure. The necessary research will take time and

the CDA has a responsibility to either support or call for change to the

status quo while the evidence is being gathered. We all seem to agree that

the CDA must not be intransigent and must support further research and

policy review in light of any new and credible findings. As stewards of

influential dental policy for Canadians, the CDA also has a responsibility

to remain sensitive to social justice issues in dentistry.

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Dr. McNally is assistant professor, department of dental clinical sciences,

faculty of dentistry, Dalhousie University, Halifax, N.S. She is a member

of the CDA ethics committee.

Dr. Downie is assistant professor in the faculties of law and medicine and

director of the Health Law Institute, Dalhousie University.

The views expressed are those of the authors and do not neces sarily

reflect the opinions or official policies of the Canadian Dental Association.

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Dr. Locker is professor and director of the Community Dental Health

Services Research Unit, Faculty of Dentistry, University of Toronto.

The views expressed are those of the authors and do not necessarily reflect

the opinions or official policies of the Canadian Dental Association.

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