Social health policies inevitably raise the issue of the individual’s freedom of choice. While debates around these policies often concentrate on questions of fact, scientific consensus and reliability of evidence, these tend to be surrogates for the underlying values issues. To what extent should I sacrifice my freedom of choice, or my freedom of choice to decide for my children, for the good health of the community? And what if my freedom of choice violates the freedom of choice for others?
Paul Offit discussed these issues in a recent Point of Inquiry podcast – Paul Offit, MD, on Measles in the Magic Kingdom and the Anti-Vaccine Movement. He is a Professor in the Division of Infectious Diseases and the Director of the Vaccine Education Center at the Children Hospital of Philadelphia. Offit is the author of the book Do You Believe in Magic?: The Sense and Nonsense of Alternative Medicine.
He basically talks about the spread of measles throughout California and neighboring states because of a source of infection at Disneyland. Although measles were eliminated in the U.S. by 2000, the misinformation of the anti-vaccine movement has caused a return of a full-fledged outbreak.
Levels of responsibility and consequences
Paul makes the comparison of opposition to vaccination with opposition to blood transfusion.
1: Blood transfusions. A person my refuse to accept treatment involving blood transfusion because of their personal religious beliefs. More questionably they may refuse on behalf of their children. However, the consequences are limited to the person or her child. The decision does not harm the community at large.
2: Vaccinations. A person may refuse a measles vaccination for themselves or their children. But in this case the consequences are not personal – they affect the whole of society. By lowering the degree of immunisation in the community they threaten the lives of others – particularly the most vulnerable, children.
In these two cases the person has refused an intervention, a medical treatment or vaccination, which could be seen to violate their freedom of choice – or even to violate their body. In the first case the consequences are personal, limited to the person who made the wrong decision. But in the second case the consequences are social. An personal wrong decision has taken away the freedom of choice, the health and in some cases the lives, of others in society.
A bit like the personal decision to drive on the wrong side of the road. Society has taken away a small personal freedom of choice in our road rules to protect the lives of all of us.
3: Fluoridation. Social health policies like community fluoridation of water, salt, milk, etc., are recognised as being safe, beneficial and cost-effective. But they are opposed by a vocal minority. Activists will passionately promote the freedom of choice argument and, considering they don’t have the scientific evidence on their side this is often seen as their strongest argument. After all, it is values-based and therefore can’t be tested and rejected by evidence.
But, this third case is different to the other 2.
- The act of fluoridation or not is social, taken by society as a whole or their representatives. An person may contribute to the decision but cannot decide the issue by a personal action as they can with vaccinations or blood transfusions. Although individual political action, or dissemination of information or misinformation, may influence that social decision – and hence the social consequences.
- Fluoridation does not involve an intervention or treatment, medical or otherwise. No one is forced to drink fluoridated water or milk, or to consume fluoridated salt. The freedom of choice argument is invalid here because there are always alternatives.
Despite actively promoting the freedom of choice argument even the NZ anti-fluoride activist Fluoride Free NZ provides information on these atlernatives. They list alternative water sources, distillation, ion exchange filters and reverse osmosis. Most of these choices are cheap and available.
So what is driving anti-fluoridation propagandists?
Unlike opponents to blood transfusion they cannot argue freedom of choice to refuse an intervention on religious grounds. There is no intervention. The only personal imposition is that they may wish to buy a water filter (many already have these) or buy water from a different source.
Again, unlike opponents of vaccination they cannot argue freedom of choice to refuse an intervention even on grounds of personal belief – because there is no personal intervention.
Given the lack of any forced or personal intervention I am forced to conclude the freedom of choice issue that concerns the anti-fluoride activists is their freedom of choice to decide the oral health quality of other members of their community. And given the health and scientific expert consensus on the issue they are really arguing for their freedom of choice to decide the oral health of others on the grounds of their own minority personal beliefs or convictions.
In last year’s High Court judgement on the question of fluoridation in South Tarinaki, Justice Hansen wrote:
“Provided it does not have consequences for public health a person has the right to make even the poorest decisions in respect of their own health. But where the state, either directly or through local government, employs public health interventions, the right is not engaged. Were it otherwise, the individual’s right to refuse would become the individual’s right to decide outcomes for others. It would give any person a right of veto over public health measures which it is not only the right but often the responsibility of local authorities to deliver.”
The freedom of choice the anti-fluoride activists are promoting is their freedom of choice to decide health outcomes for others – not themselves.