Water fluoridation is regarded as one of the largest public health interventions of modern times(1). One of its greatest advantages to humans is by limiting the decay and crumbling of teeth (known as dental caries), the tooth foundation could be effectively preserved, and several dental problems could be eliminated. Be that as it may, there has been major apprehension regarding the possible detrimental effects of water fluoridation. Also, there is a possibility that water fluoridation is causing an upsurge in the dental phenomenon of fluorosis(2).
It is a debatable topic that forcing the fluoridation of water within public drinking water is morally incorrect since it withdraws the autonomy of individuals by stripping their autonomy regarding the option to not intake any fluoride. Be that as it may, limiting the water choice for the general population may be argued based on the reasoning that it is advantageous for less economically fortunate people. Fluoride is not a cheap commodity in the context of dental interventions(3). It is argued that fluoride in drinking water is advantageous for everyone as it makes the mineral convenient, accessible, and most importantly free of charge. Because of its cost-free quality, it is evident that those who will reap the most benefits from a water fluoridation policy would be the vulnerable and disadvantaged people in the population(4). Consequently, the whole notion of water fluoridation sparks the conflicting interest between the ethical ideologies of the collective good versus the autonomy of personal choice.
Ethical consideration and evaluation are a required part of decision-making for all health policies. Ethics is the division of philosophy that touches on value-attached decision-making and behavior(5). Justifiable and correct health policy and practice need a grasp of the values that mark our options. Choices conducted in both medical practice and public health policy need to be an evaluation of the beliefs of decision-making individuals and the entire society as well(6). Ethically prudent healthcare policy-producing needs to calibrate the possible pros and cons of all other options. Evaluating the ethical justifiability of the public health policy between conflicted ideologies on water fluoridation would ergo need an in-depth evaluation of the potential advantages and disadvantages of water fluoridation.
There have been multiple ethical theories in history that were brought up to monitor the ethical behavior of human beings. The utilitarian theory marks that the morally correct notion is the one that garners the largest favorable output for the largest number of people(7). Moral absolutism is the ethical perspective that illustrates the certain rules against which ethical questions can be evaluated, and that certain actions are correct or incorrect, notwithstanding the actual nature of the action. Because of this, actions are deemed intrinsically moral or immoral, without regard to the values and targets of the person, society, or culture that partakes in the act of doing(8). On the other hand, virtue ethics is about a person as opposed to behavior-based: it takes on the perspective of the virtue or moral foundation of the individual taking part in the action, not ethical responsibilities and rules, or the repercussions of certain behaviors. Virtue ethics does not only concern the correctness or incorrectness of a person’s choice of actions, it gives support as to the sort of actions a good individual will strive to do. With that said, virtue ethics is about the holistic evaluation of an individual’s life, as opposed to a specific choice of action. Care ethics is a perspective that focuses on compassion and care toward disadvantaged people. The care ethics theory marks a defined juxtaposition to moral theories that depend on principles to emphasize ethical actions—namely the aforementioned utilitarianism and moral absolutism—and is not supposed to be absolute and indisputable.
The aforementioned systems each have their limitations, American ethicists Beauchamp and Childress brought forth the four principles approach to bioethics. The aim is to try to reconcile the differences between the various theoretical constructs by evaluating their bioethical reasoning on the more commonly approved principles such as nonmaleficence, beneficence, respect for autonomy, and justice. This framework can be applied to evaluate the conflicting ideologies of serving the collective good versus the freedom of individuals behind the water fluoridation conundrum. These principles are thought by many to be the standard ethical theoretical framework for the breakdown of bioethical dilemmas in the area of medicine.
Autonomy
Autonomy, simply put is the choice of free will for individuals. In the case of water fluoridation that autonomy of individuals is undoubtedly compromised as individuals do not have the freedom to choose to extricate themselves from this decision, there is after all only one public free flowing water source available. The opposition to water fluoridation may attach the label of mass medication for this public policy. However, it can be argued that modulating the level of a mineral that is already naturally present in the water is not considered a form of compulsory medication. Involuntary medication in a clinical setting is primarily referred to psychiatric treatment that is conducted in spite of a person's objections. These are generally patients with severe mental disorder and are evaluated by physicians to be a danger to the society. Also, it could be debated that those opposed to water fluoridation could possibly lessen or extricate fluoride from the drinking water through the installation of water filters. The most effective method for fluoride filtration is activated alumina, which does not lose its efficiency nor have any possible dangers of mad cow disease prion exposure.
“Activated alumina is manufactured from aluminum hydroxide by de-hydroxylating it in a way that produces a highly porous material; this material can have a surface area significantly over 200 m²/g. The compound is used as a desiccant (to keep things dry by absorbing water from the air) and as a filter of fluoride, arsenic and selenium in drinking water. It is made of aluminum oxide (alumina; Al2O3)…It has a very high surface-area-to-weight ratio, due to the many “tunnel like pores that it has.”
Beneficence
Beneficence deals with the principle of actions with the best interest of others. Beneficent actions in a public health setting could be done to better the health situation of people. Water fluoridation can effectively aid in the protection against dental caries in humans, with research studies confirming the advantageous impact in young children and adults up to eighty years of age. Previously it has been widely suggested that water fluoridation only benefit human if the initiation of the intervention started in a person’s childhood, and therefore rendering it a less enticing intervention. However, an Australian research has produced evidence that ingesting fluoridated water can aid in the prevention of dental caries in adults of all ages, despite whether or not they began ingesting it in childhood. Utilizing a sample of 3,779 grownups from the Australian National Survey of Adult Oral Health in 2004-2006, grownups who had spent more than three-quarters of their lifetime susceptible to fluoridation had substantially less dental caries than those who had less than a quarter of their lifetime exposed to fluoride, even if the fluoridation experience began after childhood.
The dental statistics also show that adults residing in more favorable fluoridated areas have significantly less root surface dental caries compared to those residing in areas without the favorable water fluoridation. Also, water fluoridation is advantageous to communities of lower socioeconomic backgrounds, which often may have a higher prevalence of dental caries and reduced access to alternative methods of fluoride and dental interventions. Essentially, the beneficence of water fluoridation summarizes to the reduction of the socioeconomic inequities in dental caries phenomena and is the most socially equitable method of attaining a wide exposure to the dental mineral of fluoride.
Non-maleficence
This principle deals with the actions of doing no harm and is frequently analyzed when concerning medical decisions with a blatant risk but comparatively reduced possibility of benefit. The intake of an excessive amount of fluoride can lead to the ailment of dental fluorosis. Dental fluorosis is the changed shape of tooth enamel as a result of an inordinate amount of fluoride ingestion amid the timeframe of tooth development, most often from birth to approximately six to nine years of age. The most ubiquitous (and most temperate) fashion, it may develop as virtually unnoticeable with slight whitish stipes, whereas more aggressive formations involve merging pitting and splotches on the dental enamel. Figuring out the exact level of dental fluorosis within an area is not easy, as there are many other reasons for enamel damage that may be similar to dental fluorosis. Ergo, it is difficult to form a causal relationship between water fluoridation and fluorosis. Moreover, fluorosis in most cases is a more cosmetic problem versus a detrimental health issue. Besides dental fluorosis, the research studies have not discovered any verified connection between water fluoridation and detrimental impact to humans. In the year of 2006, both the World Dental Federation and the International Association for Dental Research along with the World Health Organization attested that water fluoridation is harmless and works well, consequently they commended governments to form legislation and various interventions to make water fluoridation a more widespread movement. Those opposed to water fluoridation frequently assign a multitude of risks caused by water fluoridation; namely bone fracture or bone tumor, but such risks have been often considered as unproven and inaccurate. The York Review have said that there is no reliable evidence of a scientific connection between water fluoridation and death or mortality as a result of cancer. The York Review came to this conclusion following the evaluation of ten studies with different forms of analyses. The greatest available results supporting the connection of water fluoridation and bone fractures display zero association. Furthermore, the most optimal available evidence on connection of water fluoridation and cancers also demonstrate zero association. The assorted detrimental effects studied did not give sufficient evidence that is of quality on any specific result to arrive at any scientific conclusions. The York Review also added while fluorosis can happen in the period of a couple years of exposure amid tooth development, alternative possible detrimental effects could need long-term exposure to actually happen. There is a possibility that the long-term exposure was not included in the studies that were analyzed.
Justice
The principle of justice could be viewed as the ethical requirement to act on the foundation of fair judgment between competing claims, this is connected to fairness and equality. The two presiding elements of the principle of justice are namely equality and equity. The definition of equality is treating everyone one the same; whereas equity is providing people with what they need to become successful. There is a finite amount of resources that could be distributed to aid the community that pertains to the realms of distributive justice. For example, in the United States there is no other feasible alternative to the practical and effective water fluoridation for reducing the socioeconomic status-based disparities. An ideal solution, such as an in-school dental program, found in several wealthy countries, would need the allocation of significant publicly funded resources, and that is not a feasible option atleast in the near future. However, researches in America, United Kingdom, Australia, and New Zealand have shown that water fluoridation not only mitigates the overall rate and severity of dental issues, but also lessen the disparities between socioeconomic status groups. More on this topic have been carefully studied to compare the socio-economic paradigms of children’s dental caries in Canada, in 2009-2010 when community wide water fluoridation was in action, and also in 2013-2014, after it the end of water fluoridation. Data were taken from samples of youngster in grade two, and record on dental health were grouped from dental examinations done in schools by dental professionals. It was conducted to examine the association between tooth decay and the existence of dental insurance and small-area index of socioeconomic deprivation. There was substantial inequitableness by dental insurance situation and by small area socioeconomic deprivation were more apparent in 2013-14 than in 2009-10. The outcomes align with increasing inequitable distribution in tooth decay following termination of community water fluoridation. This study is important because unlike many other cross-sectional studies, it pointed to the impact the termination could have on the status groups, versus the commencement or during water fluoridation. It provided another perspective to solidify water fluoridation’s potential contribution to social equity.
Utilizing the Beauchamp and Childress ethical principle framework it is possible to delve into the moral reasoning concerning this water fluoridation conundrum. Through this framework the aim to reconcile these differences is a possible but in no way, shape, or form a conclusive method to determine the suitability of a health policy for the public. After all, there are a multitude of ways of how a situation could be interpreted under the four principles of autonomy, beneficence, non-maleficence, and justice. The ethical appropriateness of a health policy is subjective to various perspectives of individuals, groups, and communities. The effort to truly reconcile the conflicting ideologies of collective good versus individual autonomy is difficult as to implement water fluoridation or not will always result in satisfaction among opposing groups. The importance of health policy in its essence is to better the health of public and the benefit must outweigh the possible risk. In this case, though the framework it can be reasoned that it is possibly ethically justifiable to implement water fluoridation. This is because there is concrete evidence on how it can benefit the population and weak evidence on the detrimental impact it may have on the public.
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References
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