Ethics of Enriching the Water Supply

How can we bring our communities the best of science while respecting each person's values?

SSVMS was part of that lengthy debate and repeatedly gave thoughtful consideration to the subject and decided that the benefits far outweighed the risks. Although a few physicians and dentists still murmured their misgivings, the benefit of low cost prevention of dental caries overcame such muffled professional angst, as well as the shrillness of anxious extremists who oppose "better living through chemistry." Physicians and dentists who generally oppose bureaucratic intrusion in personal lives dismissed their qualms. The goal, preventing childhood dental caries, still far outweighed the risks.

As so often happens, we failed to understand that the murmurs and shouts of opponents were the noise of underlying discomfort, something that might merit attention. It is hard to enunciate-or listen to-the discomforts that arise when our core personal and cultural values clash with our professional ethics and scientific knowledge.

Science and technology now increasingly pose that challenge.

An already anxious public, and some concerned scientists and physicians, still worry about fluoridation. It treats what might ail the drinker, not what might ail the water. That makes it different from chlorination. It protects against a condition that is not contagious and does not endanger the health of others. That makes it different from vaccination and immunization.

Dental caries is a personal health problem with great personal health and economic costs, but preventable and treatable through local and systemic treatments and altered life styles. In that way dental caries seems more like depression and obesity, widespread and treatable and prevent-able through psychotropic agents or appetite suppressants. Those alternatives, though, require personal and family choice, time, attention and money-all of which reduce compliance. For better compliance we need only add a safe, inexpensive drug to the water.

The four basics of medical ethics are to do good, avoid unnecessary harm, be "just," and respect the autonomy of the patient. Fluoridating the water supply offers benefits that far outweigh the risks of harm and provide for equitable, low cost distribution. However, it treats someone who is not fully informed and does not have a revocable choice at the time of each treatment.

Would we consent to adding lithium or an appetite suppressant to treat depression or obesity? Such treatment would violate the religious beliefs and personal preferences of a minority. Except to prevent a disease that endangers the community, we have never before required such an unavoidable application of a medical procedure that violates personal autonomy. Failure to prevent or treat dental caries, depression and obesity endangers only the individual directly, the community only by the indirect effects on the family and the costs to the community of subsidized treatment and reduced health and productivity. Yet we have decided to treat only one condition universally.

Is it because fluoridation is overwhelmingly beneficent or is it that we are still waiting for the safe, low-cost, water-soluble mood stabilizer and appetite suppressant? Would we endorse and support such intrusive, irrevocable interventions when they become available? Does the risk-benefit ratio of fluoridation change when we include the social cost of being perched on the "slippery slope" of adopting new technologies that might deprive us of personal choice?

We have to individualize our decisions and consider the specifics of what is possible, what disease or condition we aim to prevent, and what the ethical, financial and scientific risks and benefits are-including what it does to or for the dignity of our patients.

Intervention through a public water supply when other effective interventions are available requires us to determine what blocks access to the alternatives. Maybe we need to try harder to change social attitudes before we engage in universal treatment to benefit a targeted population through eroding the privacy and autonomy of everyone.

Ed_Rudin@macnexus.org