Schaub 6:00
L18
TRULY ETHICAL DECISIONS DEPEND ON COMPREHENSIVE KNOWLEDGE
OF THE SUBJECT AT HAND
Abhinav Garg (abg26@pitt.edu)
CURRENT POSITION AND ETHICAL
CONFLICT
I am currently a part of an engineering company, which was
funded by the United Nations. This particular project is in the
scope of worldwide oral health. I am in charge of determining
whether or not the country of Norway would benefit from
public fluoridation of water supply.
GENERAL IMPACT OF FLUORIDE
ABSORPTION/INGESTION ON
BIOLOGICAL SYSTEMS
There are very many aspects to analyze when
determining whether a specific area would fully benefit from
fluoridation. The most important thing to consider would be
its impact on human health. If we can determine that this
process has viable health benefits, we can move on to the
next point of consideration. It is widely known that fluoride,
in a correct dosage has positive effects on communities
suffering from dental caries. According to a report from two
Canadian cities, (one with fluorinated water, one without)
fluoride also impacted bone density of the entire skeletal
system, not just the teeth. People from the city receiving
fluoridated water had bone densities with an average of
0.15g/cm3 more than the city not receiving fluoridated water.
The fluoride also apparently strengthened the breaking point
of bone by an average of 0.12 MJ/m3 [1]. These are clearly
positive effects, which fluoride played a direct role in, and are
some major reasons fluoride is infused into tap water in the
first place. Although this is true, negative effects due to
incorrect dosage cannot be discounted.
There are many detrimental effects that can occur on
biological life, given a larger dose of fluoride. In an extensive
experiment determining effects of over fluoridation of water
in a carp (fish) environment. After 90 days in controlled
conditions, provided enough food to allow for healthy
growth, carp exposed to higher levels of fluoride (124mg/L)
had a 45.1% decrease in weight when compared to control
carp, which were in very low concentrations of fluoride
containing water. The bodies of the carp water with a
midlevel concentration of fluoride, (63.3mg/L) experienced
drastically lowered levels of total available protein, albumin,
globulin, and glucose after 90 days. Even the carp exposed to
“safe” concentrations of fluoride (35 mg/L) displayed an
increase in absorption of both Potassium and Mercury ions
after a mere 30 days [2]. Clearly, a larger dose of fluoride has
a detrimental effect on biological life, when compared to low
or nonexistent concentrations. When rats where given doses
University of Pittsburgh, Swanson School of Engineering 1
2013-10-29
of normally fluoridated water over 30 days, sections of their
liver and muscles showed lowered oxygen consumption and
retention [3]. This is valuable information because it proves
that even though fluoride can strengthen bone and help cure
dental caries, prolonged, and excessive exposure is not
beneficial to major organs, or bodily muscles.
Now we can examine the effects of excessive fluoride intake
on the human body. A toxicity report of fluoride says that
excessive fluoride intake can result in “fluorosis, which is
characterized by dental mottling and skeletal manifestations
such as crippling deformities, osteoporosis, and
osteosclerosis.” Fluoride is also known to have an effect on
soft cells in the body. Once ingested, F- (fluoride ion) quickly
bonds to an H to form HF, (hydrogen fluoride) which can
easily diffuse through the intestine membrane. Once through,
F- trades the Hydrogen bonded to it for a Ca+2 or Mg+2
(calcium and magnesium ions, respectively), which could
result in hypocalcaemia, which is marked by low calcium
content in blood. It is also observed that infants’ calcium rich
bones retain up to 90% of ingested fluoride, which adults
retain only about 60%, even less for the elderly, who may in
fact be the ones who need it the most [4]. Fluoride has a
NOAEL (No Observable Adverse Effect Limit) of about 0.15
mg fluoride/kg/day. This can be adjusted to reflect a MRL
(minimal risk level) of 0.05 mg fluoride/kg/day. Higher
fluoride intake could result in nasal and urinary tract
irritation, inflammation in both nasal cavities and bronchioles
in the lungs [5]. This is very important information, because
it shows that fluoride concentrations in tap water are not low
enough that one would have to drink an unlikely amount of
water before it harms him/her, but is in fact a legitimate
concern with very possible adverse effects.
LOCALIZED RISK AND BENEFIT
ANALYSIS
As you can see, Fluoride can have legitimate desirable effects
on the human body, but these benefits can quickly become
undesirable when the body is given a bit too much fluoride. It
is known that dental caries largely start and manifest during
childhood, because this is the time when dental hygiene
practices are developed, and when teeth are more vulnerable
to sensitivity. Because of this fact, I will focus on the children
of Norway for this analysis. Norwegian children (12 years
old) are known to have the highest average of DMFT,
(Decayed, Missing & Filled teeth) estimated at 1.7 DMFT per
child. Norway currently does not officially allow programs
for the fluoridation of water or salt [6]. Although this is true,
lack of publically administered fluoride may not be the sole
Abhinav Garg
reason that children are experiencing such shocking rates of
DMFT.
Parents of children may also be a large influencing factor due
to fact that a child’s dental hygiene routine has a direct
correlation with their respective parents’ and family’s dental
hygiene routines. Even factors such as family income level,
number of children in a family, and a change in family status
can impact a child’s oral health. Conditions such as parental
knowledge in oral hygiene, and social and cultural
background have been associated with the development of
caries early in one’s life. A parent’s negative attitude towards
dental care may result in a child not receiving regular dental
service, contributing to lesser general dental hygiene, and the
absence of periodic professionally applied fluoride gel, which
is the most locally effective, and concentrated delivery
method of fluoride to the teeth. Lack of parental appetite
control on children can result in excess sugar intake, which
can contribute to the development of dental caries. Maternal
obesity, and fat and sugar intake during pregnancy also has a
considerable impact of a child’s vulnerability to caries upon,
and after birth. If a parent is not forceful in their efforts in
getting their children to brush their teeth twice a day, (or even
in general behavior management) has a strong correlation in
caries development [7]. This proves that even though
fluoridation of water or salts is not prevalent in Norway, this
does not mean that fluoride would an absolute solution to the
problem of high mean DMFT rates in children.
dissolves sodium fluoride or silicofluoride in powder form (to
increase surface area) in a water supply, to medium sized
towns. A solution feeder is a pump allowing a certain
quantity of hydro fluorisilic acid in proportion to water and is
used in medium to large towns. The downfall and point of
consideration to implement these systems, that fact that they
require a steady supply of electricity, and capable operators to
periodically monitor PPM rates, and hourly check the weight
of fluoride in the given hopper. They also need to be tested in
various locations so determine uniformity of concentration of
fluoride throughout the system. If these requirements are
economically viable in a given area, a few more requirements
must be met for the system to be logically viable. This system
would only be reasonable if people decide to drink water
from public supplies, or from personal water tanks/wells [9].
DETERMINING ETHICAL VIABILITY
Michael S. Pritchard of Western Michigan University
described ethical viability by relating it to risk. The
possibilities of failure in a project, the failure’s implications,
and ability to reduce chances of failure all relate to the
“acceptableness” of a given risk. If we have a project with a
very low risk, there still needs to be a game plan to fix the
implications, should there be a catastrophic failure [10]. To
relate this to fluoridation of tap water in a country which has
never done so before, the “project” would be considered
setting up the system of fluoride delivery in public water
supplies. This project has a clear risk of members of the
community receiving too much fluoride, and thus developing
dental fluorosis. This risk is low because there are very few
people who are in the high risk group, and many of them
would not drink enough of this tap water to develop fluorosis.
Although this chance is small, if the system of fluoridation is
implemented, the community’s rates of caries and fluorosis
would need to be closely monitored. If the rate of caries in
children did not substantially decrease, or if the prevalence of
fluorosis became considerable, the project should be
considered a failure, and the system should be removed.
Josep M. Basart wrote about ethics in terms of
responsibilities of an engineer. These are responsibilities to
one’s self, the community of engineers, and the world as a
whole. When an engineer makes a decision, he should be able
to make it on the spot, and without a second guess. This is
because when considering a problem, one should not be
conflicted in whether or not it is ethically viable, but should
be able to determine if it will be good for the image of the
society of engineers as a whole, and for the sustainability of
the world we all live in. Basart wrote that an ideal engineer
should be able to not only take responsibility for his own
actions on a project, but be willing to confront the challenges
and perils of others [11].
IS FLUORIDATION OF WATER FEASIBLE
IN THE GIVEN AREA?
When determining whether a given community of people
would benefit from fluoride in public water supply, we need
to consider the baseline levels of caries/fluorosis, and the
amount of fluoride found in an average diet. Even if we know
that extra fluoride distribution would help in caries
prevention in people of a given area, we still have to consider
whether or not the system itself would be a smart decision.
There are also many different sources of the actual F- ion, and
many different types of fluoride distribution systems needing
consideration. Sodium Fluoride would be one of the best
sources of the F- ion because it does not contain many other
elements to contaminate the water supply, except that this
compound is unreasonably expensive. Sodium silicofluoride
is currently one of the most popular and widely used
compound for fluoridation of water supplies around the
world. This compound has a low initial cost, but is corrosive
to water systems. This is recovered as a byproduct from
phosphoric acid plants processing phosphate rock. Another
considerable option is fluorspar, (CaF2) which is recovered as
a byproduct from uranium enrichment, stainless steel
pickling, and petroleum alkylation. This is usually imported
from China and Mexico [8]. There are also a few different
pieces of equipment to use for this process of distributing
fluoride to a given population. A dry feeder automatically
CODE OF ETHICS APPLICATION
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Abhinav Garg
Any project in the field of engineering can be viewed under
the scope of ethics and how morally “justifiable” a certain
action is. The National Society of Professional Engineers
(NSPE) has written out a formal, and comprehensive code to
ensure their engineers are not conducting “immoral” projects
or experiments [12] [13]. This is important, because no
matter how important or interested an engineer is in a
particular field of study, he is professionally obligated to
discontinue it if it had any chance of harming the public.
The first canon of the engineering code of ethics states that
one should “hold paramount the health, safety, and welfare of
the public. Fluoridation of tap water would hypothetically
help the elderly with bone density problems, and the young
with dental caries problems, but for a good portion of the
population, the risk of dental fluorosis becomes very real due
to the fact that there is a very real risk of ingesting too much.
The fifth canon warns against deceptive acts. If an engineer
decided to go ahead with this proposed project, they would
have to undergo deception because he would emphasize its
beneficial effects, and understate the possibility to develop
dental fluorosis.
I think that if I was in the shoes of an engineer facing the
question of fluoridating a country’s tap water, I would take
this to heart. In my opinion, I think it would be a smarter
decision to educate the given population about proper dental
hygiene, free of cost, rather than implementing a water
system which could possibly cause more harm than good. I
also feel this way, because I think that forcing people to take
fluoride in a way they cannot easily avoid, is like playing
God in a way. I think people should be able to make informed
decisions about receiving a certain drug, and if they don’t
deem it necessary, they shouldn’t have to take it. I think that
fluoridation of communal water is a very objective thing to
do, because even though the system may help some people, it
won’t do anything to help those with normal tooth and bone
health. Those healthy people will be paying their taxes for
fluoridation systems to be built and monitored so the ones
with dental caries will be benefitted, even if the caries
resulted of their own negligence. Overall, I don’t think any
government needs to tell its people to take a certain medicine,
but instead, medicine should be an individual’s option.
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Fluorine.” (Online report).
http://www.atsdr.cdc.gov/ToxProfiles/tp11.pdf.
REFERENCES
[9] Pn. Shabeel. (2010). “Water Fluoridation.” Dentos Kerala.
(Online ppt). http://www.slideshare.net/shabeelpn/waterfluoridation.
[1] D. Chachra. (2010). “The Long-term Effects of Water
Fluoridation on the Human Skeleton.” Journal of Dental
Research. (Online report).
http://jdr.sagepub.com/content/89/11/1219.full.pdf+html.
[10] M. Pritchard. (2013). “Engineering Ethics: Looking
Back, Looking Forward.” Science and Engineering Ethics.
(Online article).
http://download.springer.com/static/pdf/811/art%253A10.100
7%252Fs11948-012-93747.pdf?auth66=1383085587_fa76b972308fc365b5204d8021c6
2a5c&ext=.pdf.
[2] J. Chen. (2013). “Effects of fluoride on growth, body
composition, and serum biochemical profile in a freshwater
teleost, Cyprinus carpio.” Environmental Toxicology and
Chemistry. (Online report).
http://onlinelibrary.wiley.com/doi/10.1002/etc.2305/full.
[11] J. Basart. (2013). “Engineering Ethics Beyond
Engineers’ Ethics.” Science and Engineering Ethics. (Online
article).
http://download.springer.com/static/pdf/755/art%253A10.100
7%252Fs11948-011-9293z.pdf?auth66=1383085399_78ba1e6c120a9f41a771f13cb06c
40d9&ext=.pdf.
[3] B.L. Fina. (2011). “Effect of fluoride on oxygen
consumption (OC) by rat tissues”. Science Direct. (Online
article).
http://www.sciencedirect.com/science/article/pii/S875632821
1008313.
[4] O. Barbier. (2012). “Molecular mechanisms of fluoride
toxicity.” Elsevier Ireland. (Online article).
http://www.sciencedirect.com/science/article/pii/S000927971
0004631.
[12] “Code of Ethics for Engineers.” National Society of
Professional Engineers. (2007). (Online document).
http://www.nspe.org/resources/pdfs/Ethics/CodeofEthics/Cod
e-2007-July.pdf.
[5] Agency for Toxic Substances and Disease Registry.
“TOXICOLOGICAL PROFILE FOR FLUORIDES,
HYDROGEN FLUORIDE, AND FLUORINE”. (Full online
report).
http://www.atsdr.cdc.gov/ToxProfiles/TP.asp?id=212&tid=3
8.
[13] “Code of Ethics.” American Institute of Chemical
Engineers. (Online Code of Ethics).
http://www.aiche.org/about/code-ethics.
ADDITIONAL SOURCES
[6] M. Connett. (2012). “Tooth Decay Trends in Fluoridated
vs. Unfluoridated Countries” Fluoride Action Network.
(online article). http://fluoridealert.org/studies/caries01/.
G. Adams. (2010). “How does a reverse osmosis system
work?” Water Filter Guy. (Online video).
http://www.youtube.com/watch?v=rG29fwWoNkc.
[7] T.I. WIGEN AND N.J. WANG. (2012). “Parental
influences on dental caries development in preschool
children.” Department of Paediatric Dentistry and
Behavioural Science, Institute of Clinical Dentistry,
University of Oslo, Norway. (Online research report).
http://www.ntnu.no/ojs/index.php/norepid/article/view/1515/
1351.
Wolfram Alpha. (2013). “Fluoride.” (Online database).
http://www.wolframalpha.com/input/?i=Fluoride.
AKNOWLEDGEMENTS
I would like to thank Hunter Gaston for starting this paper at
the same time as me, and acting as a reference for timeliness.
Also for encouraging me and explaining the topic of the
paper more clearly.
[8] Agency for Toxic Substances and Disease Registry.
“Toxicological Profile for Fluorides, Hydrogen Fluoride, and
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