Ethical and Legal Issues in Healthcare PUB014-6

University of Bedfordshire
MSc in Public Health
Ethical and Legal Issues in Healthcare
PUB014-6
Assessment 1: Example
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Water fluoridation consists of artificially incorporating a fluoride compound to public water sources
in order to optimally increase fluoride concentration to facilitate the mass prevention of tooth decay
(Alfredo, 2016; Diesendorf, 1995). In 1945, water fluoridation was first introduced in Grand Rapids
(USA), it was found by 1955 that the rate of dental caries (decay of tooth enamel) decreased by 60%
among children born after the employment of this intervention (Awofeso, 2012b). Subsequently,
water fluoridation schemes were instituted by approximately 30 countries, with around 350 million
people consuming fluoridated water worldwide (Awofeso, 2012a, Nuffield Council on Bioethics,
2007). However, in recent years the practice of water fluoridation has been suspended in many
countries due to emerging debates about the ethical concerns associated with its imposition
(Awofeso, 2012b; Holland, 2015). Therefore, this essay will discuss the major ethical dilemmas
concerning water fluoridation considering the precautionary principle and the principles of
biomedical ethics (Beauchamp and Childress, 2013).
According to the precautionary principle, an intervention should be avoided when there is unclear
scientific evidence about its health risks (Tickner and Coffin, 2006, UNESCO, 2005). Although some
evidence suggests that consuming water containing 1 part per million (ppm) of fluoride
concentration helps reduce dental caries by 15% (Awofeso, 2012a; Awofeso, 2012b; Nuffield Council
on Bioethics, 2007), the safety of this intervention is still questionable, given that numerous studies
have associated various health risks pertaining its implementation. Moreover, recent studies have
found that drinking fluoridated or non-fluoridated water produced no difference in the level of
dental caries among children (Peckham and Awofeso, 2013).
Research evidence suggests that water fluoridation endangers health by causing dental fluorosis
(visible marking, specking, staining on teeth), skeletal fluorosis, bone fractures, cancers,
immunological dysfunction, birth defects, kidney failure, hypothyroidism, genetic damage and
cognitive impairment (Awofeso, 2012a; Awofeso, 2012b; Diesendorf, 1995; McDonagh, 2000). It has
also been found that visible effects of dental fluorosis can have an adverse impact on the
psychological wellbeing of children (Peckham and Awofeso, 2013; Nuffield Council on Bioethics,
2007). Though ingestion of fluoridated water has been linked to these negative health outcomes
apart from dental fluorosis, due to insufficient, inconclusive and low-quality evidence, a causative
association with other potential harms cannot be established (McDonagh, 2000; Medical Research
Council, 2002; Nuffiel Council on Bioethics, 2007). For instance, various studies have found that
there is no significant association between fluoride ingestion and increased risk of cancer (Awofeso,
2012a; Peckham and Awofeso, 2013). This suggests that more robust scientific evidence is required
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before a clear link with other potential harms can be established (Diesendorf, 1995, Medical
Research Council, 2002).
Furthermore, using the precautionary principle to oppose water fluoridation, it can be argued that if
its imposition only reveals modest benefit (i.e. prevention of dental caries) (Peckham and Awefeso,
2013) and demonstrates considerable risks of causing diseases, the precautionary approach will
encourage discontinuation of such intervention in order to protect people from potential harm, this
is in accordance with the ethical principle of non-maleficence (Awofeso, 2012b). Diesendorf (1995)
maintains that the real magnitude of the benefits water fluoridation is unclear, therefore it is likely
to be overestimated. Hence, it can be argued that it is desirable to take precautions against a
strategy with uncertain evidence because fluoridated water is consumed by millions of people
around the world, therefore when a large number of the world’s population is exposed to the same
intervention, it is worth weighing up the benefits against the dangers as a small risk could lead
severe health consequences (Alfredo, 2016).
Contrary to the above, Martuzzi (2007) uses the precautionary principle in favour of water
fluoridation and maintains that scientific ambiguity should not be used to as a motive to ignore
preventative actions for adverse health outcomes. This argument is reinforced by Nuffield Council on
Bioethics (2007) which maintains despite unclear evidence of potential harms, public health
measures should be implemented to strive for the ‘common good’. It has been found that in areas
where natural concentration of fluoride is 1ppm and no safety measures have been implemented to
remove fluoride, the health of local residents has not been impaired (Hull City Council, 2017). This
suggest that consuming 1ppm fluoridated water may not endanger health of the population,
therefore its imposition could be justified as it is beneficial for preventing dental caries. In addition,
proponents of water fluoridation justify its imposition by proposing an additional benefit, they argue
that water fluoridation helps achieve the central goal of reducing health inequalities as people from
lower-socioeconomic background can also benefit from it (Diesendorf, 1995). However, Peckham
and Awofeso, 2013 argue that the evidence for this is of poor quality, therefore it provides weak
support.
Furthermore, some declare water fluoridation as an uncontrolled mass medication which is ethically
inappropriate (Awofeso, 2012). They argue that in practice, it is impossible to keep fluoride
concentration constant leading to some people receiving higher concentration which could possibly
be linked to increased risk of adverse health outcomes (Diesendorf, 1995). It can also be argued that
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mass medication without individual consent leads to infringement of autonomy as individuals cannot
control what they consume leading to mandatory consumption of fluoridated water even by those
who may adversely affected (ie. people with chronic renal disease) (Awofeso, 2012; Peckham and
Awofeso, 2013; Nuffield Council on Bioethics, 2007). Conversely, it can be argued that flowing the
principle of ‘beneficence’ (promoting good for society) local authorities must introduce interventions
that produce positive health outcomes (Hull City Council, 2017). However, the degree to which the
state can intervene in people’s personal choices remains an ethical concern.
The precautionary principle requires us understand whether benefits of fluoridation can be attained
though possibly less harmful sources (Tickner and Coffin, 2006). It is now widely accepted that
fluoridation provides benefits through topical action rather than ingestion to prevent dental caries,
therefore it can be argued that more effective and possibly less harmful ways of fluoride
administration can be achieved through alternative sources such as tooth pastes, milk, tea, mouth
rinses etc. (Awofeso, 2012; Diesendorf, 1995; Goldman et al., 2008; Nuffield Council on Bioethics,
2007). In this way the concentration of fluoride could easily be monitored and controlled, in
addition, the ethical principle of ‘autonomy’ will not be violated.
To conclude, although water fluoridation is beneficial for dental caries prevention, some research
has established an association with adverse health outcomes. Yet there is lack of scientific research
to support this. Therefore, it is advisable to refrain from such an intervention until conclusive
scientific evidence is provided. Utilisation of alternative sources appear to be a better option as they
provide the same health benefit and greater control over dose exposure. The violation of ethical
principles is also minimised. Therefore, the imposition of water fluoridation is questionable.
Word Count: 1118
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References
Alfredo, M. (2016) ‘Community water fluoridation: open discussions strengthen public health’,
American Journal of Public Health, 106 (2), pp. 209-210.
Awofeso, N. (2012a) ‘Artificial water fluoridation: environmental and human health effects’, Health
and the Environment Journal, 3 (2), pp. 10-16.
Awofeso, N. (2012b) ‘Ethics of artificial water fluoridation in Australia’, Public Health Ethics, 5(2),
pp.161-172.
Beauchamp, T. and Childress, J. (2013) Principles of biomedical ethics. 7th edn. New York: Oxford
University Press.
Goldman, A. S., Yee, R., Holmgren, C. J., Benzian, H. (2008) ‘Global affordability of fluoride
toothpaste’, Globalization and Health, 4 (1), p. 7.
Diesendorf, M. (1995) ‘How science can illuminate ethical debates a case study on water
fluoridation’, Fluoride, 28 (2), pp. 87-104.
Holland, S. (2015) Public health ethics. 2nd edn. London: Polity.
Hull City Council (2017) Water fluoridation: ethical issues. Available at:
http://www.hull.gov.uk/sites/hull/files/media/Editor%20-
%20Environmental/Ethical%20issues.pdf (Accessed: [Date]).
McDonagh et al. (2000) ‘A systematic review of public water fluoridation’, BMJ Clinical Research, 321
(7265) pp. 855-9.
Medical Research Council (2002) Water fluoridation and health. Available at:
https://www.mrc.ac.uk/publications/browse/water-fluoridation-and-health/ (Accessed:
[Date]).
Martuzzi, M. (2007) ‘Editorial: The precautionary principle: in action for public health’, Occupational
and Environmental Medicine, 64 (9), pp. 569-570.
Nufflied Council on Bioethics (2007) Public health: ethical issues. Available at:
http://nuffieldbioethics.org/wp-content/uploads/2014/07/Public-health-ethical-issues.pdf
(Accessed: [Date]).
Peckham, S. and Awofeso, N. (2014) ‘Water fluoridation: a critical review of the physiological effects
of ingested fluoride as a public health intervention’, The Scientific World Journal, 2014, pp. 1-
10. doi: http://dx.doi.org/10.1155/2014/293019
Tickner, J. and Coffin, M (2006) ‘What does the precautionary principle mean for evidence-based
dentistry?’, The Journal of Evidence-Based Dental Practice, 6 (1), pp. 6-15.
UNESCO (2005) The precautionary principle. Available at:
http://unesdoc.unesco.org/images/0013/001395/139578e.pdf (Accessed: [Date]).