The Ethical Implications of Adding Fluoride to Drinking Water

by Dr. Nileema Conlon Vaswani in

We would all like healthy teeth and fewer visits to the dentist. Most of us also agree that prevention is better than cure. Why, then, has the UK Health Minister’s suggestion that fluoride be added to drinking water caused so much controversy when the idea behind this suggestion is that, because fluoride can help prevent tooth decay, people will have healthier teeth?

There are several issues to consider in this debate, the first of which is a medical one. The British Dental Association has argued that fluoride has tremendous benefits and that places where fluoride is present in drinking water reveal a population with healthier teeth than those places that do not have fluoride in their drinking water supplies. The USA is a case in point as well. Many parts of the country have had fluoride added to the water supplies and have revealed better dental results than places where there is no fluoride in the water.

Opponents of the move to add fluoride to water have argued that the mineral can have side effects including cancer, thyroid problems, mental problems, osteoporosis and brittle bone disease. None of these are minor medical conditions and if fluoride in water presents a real risk of one’s developing these side effects, we have reason to be careful before deciding if fluoridated water is the best way forward. We should be careful to ensure that we are not trading in one set of health problems, i.e., dental problems for another set of far more severe health problems like cancer, mental health or any of the other mentioned side effects.

Those who are in favour of adding fluoride to water claim that the critics have made "unsubstantiated claims" and that there is insufficient medical evidence to point to these feared side effects. It is not possible to comment on either the accuracy of this claim or the claims that put forward the side effects. For the purposes of this article, therefore, I will assume that the adding of fluoride to water carries no health risks. It is then important to ask the following question: If it were absolutely safe to consume water that had fluoride added to it, would it be morally permissible for the government to add this mineral to our water supplies with the intention of preventing tooth decay among the population?

The answer to this question might be obvious; we might argue that we ought to add fluoride to water. However, more than mere medical facts are at issue here. There are plenty of medical "activities" that the medical profession could perform on me that might undoubtedly be beneficial to my health, either as treatment or as prevention, but we would be hard pressed to claim that these "activities" would be morally permissible. We live in a culture of informed consent where a competent adult has the right to decide either to agree to or to refuse medical intervention of any kind. Denying this right is considered an infringement of our liberties and a blow to our right to autonomy. This lack of consent is one of the reasons why the Health Minister’s suggestion has been met with opposition. By adding fluoride to the water supply, a competent adult who has the right to choose whether or not to accept a certain type of medical intervention is in fact being denied this right. If all the water is fluoridated, the choice to drink water that is not fluoridated is a non-existent one. Equally, if the government chose not to fluoridate water, there will be members of the population who would like fluoride and thereby not have their choice to drink fluoridated water honoured. This concern would perhaps continue to be addressed as it is at present by making fluoride tablets available in pharmacies and also toothpaste and mouthwash that contains fluoride available in stores. Consider, however, how those who are opposed to fluoride might react if they were told that although the water supplies were fluoridated, they had the option of buying bottled water that was not. In both cases, people would have to undergo certain expenses so as to be able to exercise their choices.

Regardless of our fears that Britain is becoming more and more like a "nanny state" where public choice is diminishing, it is important to recognise, as argued above, that the choice on the part of the government not to intervene is also a choice. The decision not to add fluoride to water is as much as choice as the decision to add fluoride. So how ought the government to make decisions that will invariably please some and disappoint others? What ought to be the moral basis of decisions that govern public health rather than the health of each individual? In the absence of individual consent, where each person could be consulted as is the case with medical treatment or preventive measures that are provided for the individual, the only moral route that the government can take is one that that maximises the health of as many people as possible. And it is here that we struggle with the idea that this is the only way that the Government can and ought to decide. Our opinions about what the Government ought to do are usually governed by the manner in which the decision in question will affect our lives as individuals. For the Government, though, its obligations are to its people, not to each individual person, and for this reason the moral decision regarding an issue such as fluoride in water is one that weighs up the costs and benefits of providing both types of water. This method of decision-making, although inappropriate in the case of individuals, is appropriate in the case of decisions that affect the public. Consider other decisions that the government has had to make in the interests of the public. Laws governing seatbelts, smoking, alcohol, drugs, and even childhood immunisations, are all decisions that concern the public as a whole and not just each individual. The reasoning behind these decisions is largely utilitarian, i.e., which decisions will bring about maximum benefit for the maximum number of people.

The best way for the Government to engage in decision-making that, regardless of what it decides, will infringe the liberties of some of its people is to act responsibly with regard to the findings that suggest that a certain move is in the interests of the public. In the current case, if the Government were to decide that water ought to be fluoridated, it ought to be as sure as is possible, that fluoride is in fact safe and not just beneficial. Decisions that affect individuals who are capable decision-makers themselves are difficult to justify even on grounds that the decisions are being made for their "own good". What would be even harder to justify is if the decisions did in fact result in harm. The Government has an obligation towards its people to act responsibly particularly when it is denying them the right to make decisions that affect their own lives. If this obligation were not fulfilled, then that the role of the government as protectors of the public would seriously be called into question.