The fluoridation debate: why we all lose when we pretend it’s just about science

To the delight of almost no one, water fluoridation is in the news again. A fortnight ago, Lismore Council voted to remain part of the (shrinking) 4% minority of New South Wales with no fluoride in its public water supply, despite the area’s much higher than average rate of tooth decay. An article this week in local paper the Northern Star typifies the nature of the debate: with the headline ‘Listen to science in fluoride debate, local doctors say‘, it goes on to quote GP David Guest urging councils to ‘listen to the science as the only rational way to address this important health issue.’

And that’s the problem: on this issue, arguments based on science seem to be the only currency accepted in public debate. Similar situations arise when debating wind turbines, climate change, nuclear power and vaccinations. But while good science is absolutely vital in providing solid data, there’s a limit to how far it can take us before we also need values and ethics to guide our decision. If we try to take science too far, we damage both the ethical and the scientific debates.

That’s not to say the situations necessarily get murkier if ethics are involved. In the case of fluoridation (as indeed with vaccination), I believe the ethical decision for Lismore is nearly as clear-cut as the scientific findings. But by giving less credence to objections based on values – like questions of individual risk versus common good – we make science seem like it’s the only game in town. Is there any wonder fluoridation’s opponents clutch at pseudoscience – and worse?

Let’s take a look at the recent public debate about fluoridation in the Lismore region, and see why greater scrutiny of ethical statements – and not just of science – could help everyone, and improve the way science is discussed at the same time.

A quick recap of the science

Greens party member Vanessa Ekins is the councillor who led Lismore’s successful 6-4 anti-fluoridation vote. ‘In the 1950s we thought DDT was safe, we thought amalgam in our teeth was safe, we thought lead was safe,’ she said to the Daily Telegraph, going on to say a review of new evidence is long overdue. Having not followed the fluoridation debate closely myself, I was shocked by the implication of her statement – that our scientific knowledge isn’t up-to-date. I decided to investigate.

What I found, in fact, is that research has been ongoing, and several very good studies have been carried out just in the last few years. They confirm the safety of fluoride at levels added to drinking water. In Australia, the National Health and Medical Research Council has carried out no less than four major reviews of the evidence since 1985, the most recent being published in 2007.

Ms Ekins’ comparison to DDT and mercury was a half-truth at best, and emotive deception at worst. We deserve better from any councillor – let alone one who, like Ms Ekins, has trained as a science teacher.*

Good studies have also been done on important related issues. Do Australian children drinking fluoridated water in fact have better teeth than those in unfluoridated areas, once we correct for other factors? (Yes.) Does water fluoridation benefit everyone equally? (No, it’s most beneficial for poorer people, who may not have as good teeth-brushing habits or as regular check-ups.) Since we’re an affluent country with good education, have we outgrown the need for fluoride? (No.)

Children age 4-10 in unfluoridated areas of Australia have significantly more tooth decay than those in areas with fluoridated water. Source: Australian Research Centre for Population Oral Health, Australian Dental Journal (2008)

Children age 4-10 in unfluoridated areas of Australia (concentration <0.3 ppm) have significantly more tooth decay than those in areas with fluoridated water. Source: Australian Research Centre for Population Oral Health, Australian Dental Journal (2008)

Scientists have also directly addressed the anti-fluoridation arguments, either by refuting the specific claims or the logical fallacies employed. Reading these isn’t for the faint of heart – they range from conspiracy theories involving industrial waste, to government mind-control and neurotoxicity – and I’ll leave you to find them in the wild for yourself. They’re liberally distributed throughout the comments section of any newspaper article on the topic.**

Why science doesn’t have all the answers

In the end, science can tell us what will probably happen if we choose to do something. But it can’t tell us whether we should do it.

An example: say research has shown that a new medicine can boost your brainpower and improve your mood. Take these tablets and you’ll be able to get a better job, earn more money to look after your kids, and have better quality family time, too. There’s only one side-effect: it’s highly probable it’ll take twenty years off your lifespan. What do you do?

It’s hard to argue that science can make the decision for you. It comes down to your values: is a hyper-productive life worth more to you, even though it might be shortened? Or is it better that you try and slog through drug-free, and have a longer and more ‘natural’ life?

A similar example, closer to the fluoridation (and vaccination) debate, might be something like this: there’s a medication we know is beneficial, though it might help other kids more than yours. We’re not 100% certain it’s safe (there’s always some doubt in any science finding), but we’re pretty sure. The only problem is, it only works properly if everyone gets it at once. Does minimising the risk to your child outweigh the potential benefits to others? Or, is your right to decide for yourself – your autonomy – more important than a societal decision for the greater good?

Again, these are ethics questions. They’re highly informed by the science – amongst other things, you need to know just how sure we are it’s safe (exactly what does ‘pretty sure’ mean?), and just how big the benefits are, before you can make a decision. But some people might not want to accept any risk to them or their children’s health, no matter how small. Others might not want to accept any loss of autonomy.

Being part of a society generally means we’re agreeing to compromise on certain issues. So your particular ethical stance has no guarantee it’ll be accepted by the rest. What’s clear, though, is that some debates do have to be about ethics – science can’t always have the final say.

Why using science to address ethical concerns is bad for everyone

Unfortunately, in arguments about things like fluoridation, we do often try to counter ethical concerns with science. That just leads to three big problems.

Issue 1: backing people into a pseudoscientific corner

Firstly, when people don’t think their ethical concerns are being heard, they can feel forced to argue based on science – and if no good evidence backs them up, they clutch at pseudoscience. This damages both the ethical debate and the scientific one.

Say I know that the science says fluoride is probably safe, and I accept that. But I hate the idea something’s going to be added to our water, because I think a ‘free society’ means we should all be able to choose what to eat or drink. So when Dr Guest in the Northern Star says that science is ‘the only rational way to address this important health issue,’ and people seem to agree, I realise that my opinions about my rights aren’t going to be heard. I’m terrified and frustrated. Suddenly I hear about some scientific study that ‘shows’ fluoride rots your brain. Bingo – they will have to listen to that! Now, instead of talking about the real issue – individual versus societal rights – we’re off arguing about a discredited study with a sample size of four and funding from some dental prosthesis company.

Issue 2: backing scientists into a false position of certainty

Scientists and other experts whose research is being misrepresented can get defensive. They sometimes retaliate by overemphasising the certainty of their results in the media, or ignoring bad science that’s in favour of their stance. This too is bad for both the scientific and ethical debates.

For example, GP David Guest is quoted as saying that experts have ‘agreed that fluoridation at recommended levels is the best way of preventing dental disease, and this long-running issue should be put to rest once and for all.’ I can see where he’s coming from, but this is a poor response to opponents.

Firstly, this harms public perception of science in general by pretending scientists ever declare a ‘case closed’. The more we pretend there’s no doubt in science, the more people only accept scientific findings if we say they’re totally certain—a definitional impossibility with science.

Secondly, of course scientists should (and will) keep evaluating the evidence. Maybe we will find something new, or maybe we’ll get to the point where we’re all demonstrably so good at brushing our teeth and getting dental check-ups that fluoride is no longer needed. Until then, we should keep investigating. By pretending science has given us infallible knowledge, we just give opponents new fodder every time a scientific study does point out we could be doing better.

Also, if experts are being defensive, they sometimes end up ignoring bad science if it supports their findings. The Telegraph, for example, has been running a pro-fluoridation, anti-“turkeys and loonies” campaign called ‘Stop the Rot’, where in addition to the name-calling they often rely on the wobbly platform of anecdotal evidence – like this Byron Bay mum’s kids have cavities, ergo it must be due to the lack of fluoride. Ignore bad science now, though, and you’re just inviting it back to bite you later. (‘There’s snow in my backyard, so climate change can’t be happening’ – sound familiar?)

Issue 3: look, there’s a squirrel! Science as distraction from poor ethical argument

And the last big problem is this: if we focus all our attacks on the bad science, we don’t critically examine the ethical arguments – which can sometimes be just as self-contradictory. Often, shining a light on people’s ethical claims can help hold them accountable in just as important a way as for the science.

Councillor Ekins says about Lismore water fluoridation, ‘If we’re in doubt, don’t do it‘. If Dr Guest had stopped treating this like a scientific attack, he might have had the more productive counter-question, ‘Are you sure it’s never good to do anything you’re not 100% certain about?’ Maybe then Ms Ekin would have been forced to consider whether her position is consistent with other things: that we should act on climate change, for example, which scientists are extremely sure (but can’t be 100% certain) is happening.

Ms Ekins also doesn’t think putting her kids at risk is right. But does her kids’ right to feel safe – when the risk to them is very low – trump other kids’ right to health? It’s a tricky question, and if she’s taking a stance on it, she should be very clear about her answer, and be forced to defend it. Also, since fluoride benefits disadvantaged families more, her constituents deserve to have her views out in the open and examined, given that Lismore residents’ average income is only three-quarters of the state average and the proportion of indigenous residents is nearly twice as large.

How the next-door neighbours are doing it right

While NSW Health only addresses the science in its public Q&A sheet, neighbouring state Victoria has taken a different direction, producing an excellent document that covers not only the scientific evidence for fluoridation (and directly addresses some of the myths) but also discusses the ethical, legal and economic bases for that state’s decisions. It’s a brilliant approach, and it definitely doesn’t treat anyone like they’re a ‘turkey or loony’.

And a week after Lismore council voted against fluoridation, neighbouring council Ballina (whose water too is currently unfluoridated) also voted on the issue. During the Ballina debate, science was never made the issue of the day: dissenting councillor Keith Williams said he ‘did not dispute the benefits of fluoridation’, but had ethical concerns about whether mass fluoridation went against the notion of ‘informed consent’. The fact they voted to continue with their plan to start fluoridation soon doesn’t necessarily reflect on any difference between Ballina and Lismore’s debates (not to mention that the whole issue is also complicated by an expensive and successful legal battle recently fought by the regional water provider against an anti-fluoridationist), but it does show that some councils find it possible to interpret scientific evidence, and then openly debate ethical questions on their own terms.

In summary

Using good science to counter bad science is productive. Using good science to tell us what will happen if we make a certain decision is also, of course, vital. But pretending science can tell us what decision we should make, or trying to counter ethical concerns with science, will never be helpful.

The recent fluoridation debate in northern NSW has been a microcosm of the murky delineation between scientific and ethical issues. Maybe, with better understanding of science’s limitations, we can improve the standards of debate about important issues in our society.

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* It should be noted that Ms Ekins’ concerns about the safety of fluoride isn’t the stance of the Greens Party as a whole. John Kaye, the NSW Greens health spokesman, describes himself as ‘strongly pro-fluoride’, and federal Greens leader Christine Milne recently tweeted “Science is settled on fluoride, vaccination, accelerating global warming. Greens support science and evidence based public health policy.”

** You won’t find them [pseudoscientific claims about fluoride] on this blog. As administrator, I’ve made the decision to only approve comments relevant to the topic of the science-ethics continuum in decision making. If you want to debate the actual science of fluoridation, there are plenty of other places to go on the interwebs. I just don’t have the stomach for it here.

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One thought on “The fluoridation debate: why we all lose when we pretend it’s just about science

  1. My experience with about 10 years of “discussing” and advocating for fluoridation is that stating an ethical argument is even more likely to be met by outrage and anger than the scientific issues. Of course the science must precede the ethical discussion because if fluoridation either doesn’t work or is a present danger rather than benefit to public health quite obviously it is unethical. If it is both safe and beneficial, as I believe it is, then what we have are people with mistaken scientific understanding demanding demanding that their unfounded “choice” be given more weight than a preschool child avoiding operations (2/3rds are prevented by fluoridation) or the lifelong increased risk for cavities in adult teeth or the elderly people who perhaps can no longer brush well getting more root cavities. Clearly that is an unethically selfish choice. Clearly the ethical decisions flow from the realities of the science.

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