Thinking Out Loud: The Ethics in Community Water Fluoridation

Before jumping into this, let me ensure we are all on the same page regarding the four ethical pillars.

• Beneficence: Doing good 
• Non-maleficence: Doing no harm 
• Autonomy: Respecting the right of individuals to make their own decisions 
• Justice: Ensuring fairness

The first two have their origins in the oft-repeated words of Hippocrates, “do no harm.” Autonomy was more of an 18^th and 19th-century concern expressed by Kant and John Stuart Mill, perhaps captured best by Justice Benjamin Cardoza,

“Every human being of adult years and sound mind has a right to determine what shall be done with his own body.”

Justice, the “fair, equitable, and appropriate treatment of persons,” is frequently thought of as distributive justice in the setting of public health, where it refers to an equitable distribution of healthcare resources.

Community Water Fluoridation (CWF)

Community Water Fluoridation (CWF) was a public health measure begun in the 1950s to fluoridate drinking water with the goal of reducing cavities.

From an ethical point of view, we should have no trouble recognizing the beneficence of fluoridation. There is overwhelming evidence that fluoride reduces cavities. For distributive justice, it is easy to argue that at the time of initial CWF, when the only sources of fluoride were those naturally occurring in a sparse distribution, adding fluoride was the easiest and least expensive means of equitably distributing this healthcare “good.” The only community members excluded from its benefits were those who obtained water from their own wells.

Non-maleficence, doing no harm, and autonomy are more challenging ethical concerns, making CWF an ethical dilemma. Ethical dilemmas, by their very nature, are complex and may not have a singular solution. 

Non-maleficence

Perhaps this is the most tractable of the two concerns since our knowledge of science may inform our consideration of harm. Paradoxically, it was fluoride’s most visual manifestation, discoloration of the teeth, termed dental fluorosis, that brought the element found in water to the attention of a dental citizen scientist. In identifying the cause of that discoloration, he serendipitously uncovered that fluoride reduced cavities. One of the great themes of scientific regulation has been finding the dose of fluoride that is sufficient to fight cavities and not become a “toxin.” The quest to uncover that Goldilocks dosage has become more complicated over time as the sources of fluoride, beginning with Crest toothpaste in 1955, multiplied. In the 50s and 60s, the predominant source of fluoride was drinking water, so regulation of that source in municipal water supplies could serve as a realistic proxy for cumulative exposure to fluoride. With the multiple additional sources, toothpaste, beverages, and supplements, CWF fluoridation regulatory levels are less realistic today. If nothing else, the changing value of CWF as the proxy for fluoride exposure demonstrates that any model of biological events is a transient and faint simulacrum of reality. 

Autonomy

Much of the early legal wrangling over CWF had to do with the enforced “medication” of the population through the water supply. While the courts found that fluoride was not a medication, there continues to be a concern about the imposition of fluoride, a fluoride “mandate,” upon those not choosing to reap its possible benefits and harms. Certainly, in one sense, this concern over autonomy will find echoes in the far more recent wrangling over COVID vaccine mandates. I hasten to point out that while similar, the two public health initiatives are quite different. COVID is an infectious disease, so your behavior can impact my health; our autonomies are entangled, making breaking the ethical Gordian knot impossible. Fluoridation of the water has no such entanglement, so your use or non-use of CWF will not result in more or fewer cavities for me. 

Without getting further into the ethical weeds, CWF is a restrictive choice on our individual liberties. That is, while we can find non-fluoridated water to drink and use, its additional cost makes it a restricted choice. For those opposed to fluoridation, CWF is an unsolicited and unconsented infringement. Again, those COVID echoes. 

The authors of a thought piece on CWF ethical issues offer three caveats in resolving ethical concerns.

“The process to justify public health interventions among conflicting values between individuals and society should also be justified.”

Justification does not mean majority rule, but an attempt through a diversity of viewpoints of all the stakeholders to reach a transparently arrived at consensus. A goal that is frequently aspirational. For our part, it requires citizens to understand the competing issues more deeply than is found in sound bits, TikToks, or influencer screeds.

“It is reasonable to adapt the intervention to local contexts for better implementation.”

That has been the thrust of CWF since its inception. While championed at the national level, decisions regarding what is added to our water are local and State concerns, not “Federal issues.” There are no Federal mandates respecting CWF, although there are regulations governing de-fluoridating water with natural levels that are too high. 

“Not all public health interventions initiated from goodwill are acknowledged by the general public as intended, and some even face untoward “backfire” from mutual misunderstanding.”

There is no reason to posit conspiratorial intentions, as we saw in the 1950s and again today with CWF and, dare I add, COVID. The public willingness to trust expertise has been sorely tested as our experts have been “insufficiently committed” to the transparent communication of, in this instance, scientific information. If the Washington Post is correct, “That Democracy Dies in Darkness,” then it should be fair to say that it limps along, especially concerning trust, in the shade of inadequate explanation.

Maybe the lesson here is less about fluoride and more about trust: if public health authorities want us to stop questioning their decisions, they might start by answering the ones we’re actually asking—preferably without the scientific equivalent of a shrug. As the administration changes in Washington, CWF will once again come into the national focus. We should not waste the opportunity to begin to restore the trust necessary for our public health systems to continue to serve their vital role in helping to keep us well. 

Sources: Community Water Fluoridation: Caveats to Implement Justice in Public Oral Health International Journal of Environmental Research and Public Health DOI: 10.3390/ijerph18052372