On the face of it, the case for water fluoridation appears straightforward. Control the amount of fluoride in the water supply and reduce caries. Look a little deeper, and things become much more complicated.
From an ethical standpoint, this is a case of beneficence versus autonomy. More simply, it’s a battle of benefit against patient choice.
The evidence of benefit is fairly clear. The most recent Cochrane review found that water fluoridation is effective at significantly reducing levels of tooth decay among children. (However, it should be noted that there is little evidence of similar benefit of fluoridation for adults.)
Until recently the prime driving force for healthcare was to provide a benefit to the patient. The healthcare professional would decide on a course of action, and the patient would play a minimal role in this. More recently, patient autonomy has risen in importance and we now recognise that patients have much more right to be involved in their healthcare decisions. We have moved on from the ‘doctor knows best’ situation of the 20th Century into a ‘co-diagnosis’ era.
One of the main ethical issues with water fluoridation is that it harks back to a time where this more paternalistic approach to healthcare was the norm.
With mass water fluoridation that right to choose is lost. Although the benefits for a section of the population are clear, people have a right to choose what interventions they and their children are given. And people are well within their rights to make what healthcare practitioners may consider to be a bad decision.
This dilemma is further compounded by the fact that exposure to fluoridated water does not seem to have a beneficial effect on the adult population. In a fluoridated area, adults are likely being treated without choice for no observable benefit. Fortunately, there is very little risk attached to fluoridating water, but it should be remembered that a lack of fluoride does not cause caries.
Having said this, it’s worthwhile considering that fluoridation is most likely to benefit those young people who are likely to develop caries. These are likely to be from a more socially deprived background, who are less likely to be able to afford toothbrushes and toothpaste. Is this reduction in autonomy a worthwhile trade-off to advantage those who are in most need of assistance? Would this act of social justice be acceptable at the loss of a little liberty?
This is a difficult balance to strike, so when assessing the case for and against water fluoridation, it’s also worthwhile considering alternatives that have a lesser effect on patient autonomy.
Fluoridation itself is a passive intervention. That is, the medication is given without any further preventative advice. Would the money spent on fluoridation be better allocated to a more active intervention, for example providing lessons on effective oral hygiene for young people in schools? Or perhaps providing families with young children free toothbrushes and toothpaste along with dietary advice? These active interventions may well also have the added benefit of reducing the adult caries incidence.
Of course, this isn’t an either/or situation, and the best solution is likely going to involve a multitude of interventions. It may be that the balance of benefit and patient choice is different in different areas of the country. What would be useful would be high-quality research to see which of these interventions provides the best result, both in relation to reduction in caries and cost effectiveness. Evidence-based interventions are ethical interventions.
Like most subjects, when you scratch beneath that surface, what started as ‘fluoridation = good’ very quickly turns into a complex discussion regarding, paternalism, right to choose and active vs passive interventions. Any decision taken to fluoridate sections of the water supply should consider the ethical issues and not only the positive patient outcomes.
The new episode of Incisive Decisive is a deep dive on these issues surrounding fluoridation, and more. Listen here.