Welcome to Ethics Consult -- an opportunity to discuss, debate (respectfully), and learn together. We select an ethical dilemma from a true, but anonymized, patient care case, and then we provide an expert's commentary.
Last week, you voted on whether lithium should be added to a town's drinking water.
Should Mayor Otis add lithium to the town's water?
Yes: 37%
No: 63%
And now, bioethicist Jacob M. Appel, MD, JD, weighs in:
The data supporting a link between lithium in the drinking water and lower rates of suicide is surprisingly robust. Studies in Texas, Japan, Austria, and Greece have all demonstrated similar findings; the Texas study showed a decrease in violent crimes such as homicide and rape as well. (One must emphasize that these are not the levels of lithium used to treat mental illness but trace amounts measured in micrograms per liter.) An analogy might be drawn to the trace amounts of fluoride added to drinking water to prevent tooth decay, which the CDC describes as one of the 10 greatest public health achievements of the 20th century, but which continues to be opposed by alternative medicine advocates, libertarians, Christian Scientists, and others on the political right and left. Assuming that lithium prevents suicide, this does not necessarily mean it should be added to the water supply. Rather, such a decision must be weighed against the costs of doing so, including economic expense, the rights of those opposed to lithium exposure, and concern for theoretical long-term side effects of such exposure. For all we know -- and there are no data for this, but it is always possible -- people in the lithium-exposed communities that have lower suicide rates are also less creative or courageous.
One risk of opposing the addition of lithium is falling for what is often called an "appeal to nature" -- the belief that something is better or healthier because it is naturally occurring. This concept ought not to be confused with the "naturalistic fallacy," an unrelated concept proposed by British philosopher G. E. Moore. Many substances that occur naturally, such as arsenic, are quite toxic; others that are synthetic, such as aspirin, can be highly therapeutic. Lithium occurs naturally in the drinking water in some regions and not in others, but that tells us little about whether it is ethical to add it to the drinking water where it is not present. Presumably there is not a significant difference, morally speaking, between diverting lithium-rich water to a lithium-poor watershed and merely adding the lithium to the water in the latter area. Both achieve identical outcomes, albeit one in an arguably less natural manner.
When evaluating any uses of publicly shared resources like the water supply, one should not ask whether the use is natural, but rather whether it is health-promoting or serves the public. Forming consensus on such a subject is not easy, however, as the conflict over fluoridation demonstrates. Until the public can better understand the illogic of appeals to nature, proposals like Otis' are unlikely to gain much political traction.
Jacob M. Appel, MD, JD, is director of ethics education in psychiatry and a member of the institutional review board at the Icahn School of Medicine at Mount Sinai in New York City. He holds an MD from Columbia University, a JD from Harvard Law School, and a bioethics MA from Albany Medical College.
Check out some of our past Ethics Consult cases:
Fertilize Human Egg With Neanderthal Sperm?