Contents

2.1 Ethics
2.2 Fluoridation Amounts to a Vast Human Experiment 
2.3 Individual and Patient Consent:  Are we patients of the NHS at all times?       
2.4 Medication and Human Rights      
2.5 The NHS Constitution
2.6 GPs’ Medical Ethics 
2.7 The Nuffield 2007 Report on Water Fluoridation Is it food, is it a medicine?
2.8 Summary

The issue of medical ethics could be framed in a very few words:  “My body, my choice”.  However, because of the many “actors” involved in this vexatious issue (Water Fluoridation or WF), it is necessary to identify the authorities which they depend on to provide them with credibility before we can unpick their arguments. 

These authorities need to be quoted when responding to the Public Consultation (PC).  Awareness of the protocols which bind the National Health Service can be used by responders to strengthen their case against WF.

In 2016, Public Health England (PHE) published a toolkit entitled
Improving oral health:  A community water fluoridation toolkit for local authorities

The PHE “toolkit” (paragraph 3.2) offers little meaningful practical guidance to local authorities in dealing with ethical issues raised by the public. We are instead referred to another publication written by a consortium of PHE practitioners which deals with ethics framed by political theory.  This is a “Background paper” in which there is a one-page case study on the ethical issues of fluoridation practice closely followed by the following paragraph:

Ref: Public Health England (2017). Public Health Ethics in Practice: A Background paper on public health ethics for the UK Public Health Skills and Knowledge Framework April 2017

Public health’s justification to sponsor WF seems to boil down to: “public health ethics must draw from political philosophy rather than medical ethics”.

There are several scientific and medical ‘voices’ which argue against WF and which use the medical ethical argument.  One such voice was the late Dr Arvid Carrlson, Nobel Laureate in Medicine/Physiology, 2000:

“The addition of fluoride to water supplies violates modern pharmacological principles”. (Dr. Arvid Carlsson, reported).

“Water fluoridation imposes on the public an unlicensed medication, in an uncontrolled dose, taken for a lifetime, without medical histories being known, and without health monitoring at an individual level.  Individual rights and medical ethics are crucial.”

More voices raised against the practice can be “heard” by following this www.fluoridealert.org > Medical Ethics

“Fluoridation – or any practice that uses the public water supply as a vehicle to deliver medicine – violates medical ethics in several important ways:

• It deprives the individual of his or her right to informed consent to medication.
• It is approved and delivered by people who do not possess medical qualifications.
• It is delivered to everyone regardless of age, health or nutritional status, without individual oversight by a doctor and without control of the dose.”

“The safety and effectiveness of fluoridated water has never been demonstrated by randomised controlled trials – the gold standard study that is now generally required before a drug can enter the market.”

“No doctor can force a patient to take a particular medicine. As explained by the American Medical Association, the doctor must inform the patient of the medicine’s benefits, side effects, and alternatives and then allow the patient to decide whether to take the medicine or not. With water fluoridation, health committees, city councils, and those responsible for establishing legislation simply tell the individual that fluoridated water is good for them and then proceed to add it to their drinking water, irrespective of their individual consent. Fluoridation allows the government and local authorities the right to do to everyone what an individual doctor is prohibited from doing to anyone.”

Fluoridation Is an outdated “One Size Fits All” approach to Medicine.

“In modern pharmacology, it is well known that individuals respond very differently to the same dose of a given drug. Thus, the dose of a drug that is safe for person A, may be toxic for person B. This same pattern applies to fluoride as well, as some people in society are known to be particularly vulnerable to fluoride’s toxic effects. Nevertheless, water fluoridation is based on the premise that the same dose of a medicine can be good for everybody, irrespective of their age, health, and nutritional status. Adding fluoride to water thus forces it on everyone in the community, including:

• bottle-fed babies (despite recommendations by many dental researchers that infants should not consume fluoridated water);
• individuals with poor kidney function (despite their impaired ability to excrete fluoride and their heightened risk for fluoride-induced bone damage);
• individuals with iodine deficiency (despite compelling research showing that they can suffer amplified neurological damage from low levels of fluoride exposure);
• individuals with deficiencies of calcium, vitamin C, and/or vitamin D (despite the well-documented fact that fluoride’s toxic effects on bone tissue are amplified in these individuals);
• individuals who drink large quantities of water, including athletes, manual laborers, and those with polydipsia.”

“There is no other drug on the market that is applied so recklessly.”

Fluoridation delivers fluoride for a lifetime without oversight of a doctor.

“There is a reason that society requires prescription drugs to be dispensed by a doctor or dentist: if there are unexpected side effects or the patient is particularly sensitive to the drug in question, the doctor overseeing the patient can intervene and correct the problem. There is no such oversight with water fluoridation. There is no systematic or comprehensive programme to track the level of fluoride building up in people’s tissues, or to monitor for side effects that may be occurring (e.g., routine urine and blood tests do not measure fluoride). Doctors are not trained at medical school to recognize the side effects of fluoride.  If anything, they are taught there are none.  Even when people are suffering from overt crippling forms of skeletal fluorosis (fluoride poisoning of the bone), it can take years of incorrect diagnoses and failed therapies to receive a correct diagnosis.”

Fluoridation provides an uncontrolled dose.

“Although water departments can generally control the concentration of fluoride being added to water, they cannot control the dose that individuals receive. This is because the dose depends on two factors beyond the water department’s control: (a) the water drinker’s weight and (b) the water drinker’s thirst. The less an individual weighs, the greater the dose (by body weight) they will receive for each glass of water consumed, and the more an individual drinks (and some people, including athletes and manual laborers, drink a lot), the more fluoride they will receive.”

“The uncontrolled dose that water fluoridation delivers stands in stark contrast to prescription drugs. When a doctor prescribes a drug, he or she always specifies the daily dose very carefully. Even in the same patient, the dose is subject to revision, depending on the patient’s response. No such individual tailoring occurs with water fluoridation.”

Fluoridation has never been proven safe/effective by randomized controlled trials.

“Randomized controlled trials (RCT) are the gold standard for proving whether a drug is truly safe and effective and are thus typically require before a government licensing body will allow the drug to enter the market. Although fluoridation has been going on for over 60 years, and although fluoridated water is now consumed by over 180 million Americans on a daily basis, there has never been a single randomized controlled trial to determine the safety and effectiveness of either fluoridated water or fluoride supplements. This may explain why the Food & Drug Administration still considers fluoride supplements as an unapproved new drug, despite over 50 years of dentists and pediatricians prescribing them to their patients. Keep this in mind the next time you hear a dentist or city councillor state that “thousands of studies” prove fluoridation is “safe and effective.”

“Water fluoridation amounts to a vast, poorly conducted, human experiment. Many government reviews have acknowledged that there remain many unanswered questions about fluoride’s toxicity and the short-term and long-term health effects that may be caused by chronic exposure to fluoridated water. Despite these acknowledgments, many basic – and obvious – health studies have yet to be carried out in fluoridated countries.”

The National Research Council, 2006

The recommendations below are some made by the prestigious USA’s National Research Council in 2006 after reviewing the literature on fluoride toxicity for over 3 years:

“Fluoride should be included in nationwide biomonitoring surveys and nutritional studies; in particular, analysis of fluoride in blood and urine samples taken in these surveys would be valuable.” p.11

“Carefully conducted studies of exposure to fluoride and emerging health parameters of interest (e.g., endocrine effects and brain function) should be performed in populations [in the United States] exposed to various concentrations of fluoride.” p.12

“More research is needed to clarify fluoride’s biochemical effects on the brain.” p.222

“The possibility has been raised by the studies conducted in China that fluoride can lower intellectual abilities. Thus, studies of populations exposed to different concentrations of fluoride in drinking water should include measurements of reasoning ability, problem solving, IQ, and short- and long-term memory.” p.223

“Studies of populations exposed to different concentrations of fluoride should be undertaken to evaluate neurochemical changes that may be associated with dementia. 

Consideration should be given to assessing effects from chronic exposure, effects that might be delayed or occur late-in-life, and individual susceptibility.” p.223

“The effects of fluoride on various aspects of endocrine function should be examined particularly with respect to a possible role in the development of several diseases or mental states [in the United States].  Major areas for investigation include the following:

• thyroid disease (especially in light of decreasing iodine intake by the [U.S.] population);
• nutritional (calcium-deficiency) rickets;
• calcium metabolism (including measurements of both calcitonin and PTH);
• pineal function (including, but not limited to, melatonin production); and
• development of glucose intolerance and diabetes.” (p.267)

As the Chairman of the NRC Review, Dr. John Doull, noted:

“What the committee found is that we’ve gone with the status quo regarding fluoride for many years—for too long, really—and now we need to take a fresh look. In the scientific community, people tend to think this is settled. I mean, when the U.S. surgeon general comes out and says this is one of the 10 greatest achievements of the 20th century, that’s a hard hurdle to get over. But when we looked at the studies that have been done, we found that many of these questions are unsettled and we have much less information than we should, considering how long this [fluoridation] has been going on. I think that’s why fluoridation is still being challenged so many years after it began. In the face of ignorance, controversy is rampant.”

Ref: Committee on Fluoride in Drinking Water, National Research Council of the National Academies of Sciences (2006). Fluoride in Drinking Water: A scientific Review of EPS’s Standards.  Washington DC: The National Academies Press. ISBN 10-0-309-10128-X

And thus, the experiment continues, one drip of water at a time.”

With grateful thanks to Fluoride Action Network for the loan of the above text.
www.fluoridealert.org/issues/water/medical-ethics

It is recognised that individual consent can sometimes be overridden where a measure is a “public health” one, for the benefit of the “common good” such as seat-belt wearing. But in the case of this particular medicinal intervention which affects the health of individuals, it is patient consent which has to be the overriding consideration.  “For the common good” is a subjective ideal in the case of Water Fluoridation.  Who is to say that swallowing fluoride over a lifetime is “for the common good”?  Anyone who accuses objectors of being selfish should be asked to categorically prove that it is for the common good.

Are we patients of the NHS at all times?

Is everyone living in the UK a patient of the NHS? In our view, the majority are patients because the majority is signed up with a GP even if some people have not been to see a GP for several years. People on a doctor’s list, even though there has been no recent activity or are in fact dead, are still referred to as “patients”. Clearly, those who are placed on a programme of referrals, blood tests, etc., or admitted to hospital are “active” patients.

Patient consent is a tenet of medical ethics and it is a patient’s fundamental right to decide whether or not to undergo a medical intervention, even if refusal may result in harm. This basic right should not be compromised by considerations of the “common good” – especially when those who may choose to use fluoride can get it from sources other than our water supply and many of those supplied with the fluoridated water will get no benefit from it. In fact, it causes harm and there can never be a benefit for the common good from something which causes harm. The difficulty  is to persuade the medical authorities and politicians that fluoride does cause harm because there is no willingness to listen.

Fluoride is easily obtainable by buying fluoride toothpaste. Also, the growing evidence that it is topical fluoride which prevents dental decay (and not swallowed fluoride) seems to have flown below DHSC’s radar! (Caveat: FFAUK cannot accept that fluoridated toothpaste helps to reduce decay.)

A GP’s thoughts about the absence of medical ethics

“Which doctor in his right mind would prescribe to a patient he’d never met, whose medical history is unknown and say – take as much of this as you want, for the rest of your life because some young children may benefit from it?” (Dr P. Mansfield, Templegarth Trust)

Below is an extract from a letter written to the The Lancet in 1964 by Mr A. E. Joll of Hampshire:

“In no case in our free society (except with persons in pubic care who refuse to eat or drink), is anyone compelled by law or administrative action, to take into his body a substance intended and calculated to affect the development of his body. Even when vaccination against small-pox was compulsory (and this was a measure against a contagious or infectious disease, which dental decay is not), there was an exemption for conscientious objections.

The analogy with the additives to bread, etc. is false because there is a choice between foods so “fortified” and those not so treated (e.g. wholewheat bread).

The ethical objections to fluoridation have fully and ably been exposed by a distinguished member of the medical profession, Sir Stanton Hicks, Emeritus Professor of Human Physiology and Pharmacology, University of Adelaide.  Every word of his letter deserves attention, but I quote only one paragraph:

“In 1939, following information then available, my children were already brushing their teeth with fluoride.  I am not therefore, and never have been, opposed to the use of fluoride either internally or externally for dental purposes.  I am, however, opposed in principle to the deliberate addition of any substance whatever to a public water supply with the avowed intention of influencing any physiological function of the human body. To yield on this principle will establish a serious precedent affecting the liberty of the citizen, and the responsibility of scientists in general and the medical profession in particular.” No amount of special pleading (e.g. the standardised official cliché that the proposal is only to “adjust” waters naturally “deficient” in fluorides to the “optimum” level of 1 p.p.m.) can obscure the fact that fluoridation is medication or treatment without consent of the individual – a practice which, hitherto in this country, has been regarded as reserved for totalitarian regimes, and which, if conceded in this instance, may lead, in due time,, to further similar suggestions for “adjusting” our water supplies.”

 (From Blount, P.C., 1964. Compulsory Mass Medication: A factual guide to the fluoridation issue”.)

Before moving on to expanding the discussion on the NHS Constitution and Medical Ethics, we recommend a read of the file The curious case of magnesium deficiency.

The following is an excerpt from Cross and Carton’s paper:
“Fluoridation: A Violation of Medical Ethics and Human Rights”.

“The ethical issues raised by fluoridation are ultimately grounded in the Nuremberg Code. This code established the basis for all modern medical research and treatment involving human subjects. All subsequent codes of medical ethics have their origins in this document.[1] While the wording of various codes may differ, they all incorporate the fundamental basic requirement: research, or even routine medical procedures, must be done with the voluntary cooperation of the subjects, who must be fully informed of the risks and benefits of the medical procedures in which they are involved. Medical ethics unequivocally demands that the wishes of the individual must take precedence over actions imposed by the state, unless there is a valid and wider public health concern. A state’s interest may legitimately override an individual’s wishes if a person with a potentially life-threatening and contagious disease such as measles or Lassa fever refuses to accept treatment and/or quarantine. Obviously, tooth decay does not qualify as such a disease, requiring the state to usurp individual rights. States continue, nonetheless, to insist on their “police power,” having convinced the public through press releases that fluoridation is completely benign.”

Ref. Cross, D. and R. Carton (2003) Fluoridation: A Violation of Medical Ethics and Human Rights. International Journal of Occupational Environmental Health. 2003;9:24–29.

 

“Any person who drinks artificially fluoridated water for a period of one year or more will never again be the same person”  (Charles Eliot Perkins, US Gov’t scientist who spent 20 years studying fluoride.)

 

In its Introduction, the NHS Constitution states:

“The Secretary of State for Health, all NHS bodies, private and voluntary sector providers supplying NHS services, and local authorities in the exercise of their public health functions are required by law to take account of this Constitution in their decisions and actions.” And … … “References in this document to the NHS and NHS services include local authority public health services …”

(Our emphasis)

The Introduction to the NHS Constitution is well worth a read

There can be no doubt that anything sponsored by the NHS as treatment or medicine cannot be considered without first having regard to the Constitution. Part 1 of this paper set out to establish that fluoridated water is a medicine – a prophylactic intended to cause physiological change as admitted on p. 19 of BSEN 12175:2022

“Hexafluorosilicic acid is used for the fluoridation of drinking water to increase the resistance of consumers to dental decay”.

“It is concluded that the status quo rests on the legal fiction that fluoridated water does not constitute a medication.”
Fluoridated Water Is A Medicine    

Ref :  Shaw, D. (2012) Weeping and wailing and gnashing of teeth: The Legal fiction of water fluoridation.  Medical Law International 2012 12: 11.

Finally, consumers of fluoridated water are not protected by the provisions of the Drinking Water Directive (retained post-Brexit) and since it isn’t drinking water it can only be medicinal and must be regarded as such in law.

On the basis that we’ve proven our case that it is a medicine, we will now continue and prove that WF violates the NHS Constitution. So …

1. Anything sponsored by the NHS as treatment or medicine cannot be considered without first having regard to the provisions of the NHS Constitution;
2. Public health services are included in the NHS Constitution (i.e. people who work as Public Health practitioners). They sponsor Water Fluoridation which they claim is a public health measure and which is therefore encompassed by the Constitution;
3. The Secretary of State for DHSC is also required by law to take account of the NHS Constitution.
4. The Constitution exists for the benefit of patients;
5. Therefore, patients who are “given” the public health measure (fluoridated water) are protected by the Constitution.

It would be difficult to maintain an opposite argument. We are dealing with medical treatment and are not concerned for the moment about whether or not the treatment is supplied in a neat little carton.

Principle 7 of the Constitution states:

“7. The NHS is accountable to the public, communities and patients that it serves

The NHS is a national service funded through national taxation, and it is the government which sets the framework for the NHS and which is accountable to Parliament for its operation. However, most decisions in the NHS, especially those about the treatment of individuals and the detailed organisation of services, are rightly taken by the local NHS and by patients with their clinicians. The system of responsibility and accountability for taking decisions in the NHS should be transparent and clear to the public, patients and staff. The government will ensure that there is always a clear and up-to-date statement of NHS accountability for this purpose.” (Our emphasis)

Ref: Department of Health and Social Care (updated January 2021). The NHS Constitution for England. https://www.gov.uk/government/publications/the-nhs-constitution-for-england/the-nhs-constitution-for-england#principles-that-guide-the-nhs, Principle 7.

When we are fluoridated, we are supplied with the treatment for a lifetime if we remain in the fluoridated area.  But no-one ever asked us if we wanted to be fluoridated in 1964!  Successive laws prevented WF programmes from being reviewed or terminated if they were initiated prior to the practice being made legal in 1985.  So, communities have been locked into WF by a legal sleight of hand.

Whilst individual patients can confer with their health provider, a multitude of fluoridated patients all speaking with one voice are not permitted to confer!  There is also a pernicious legal clause which states that once you have attempted to stop fluoridation in your area, and have failed, you cannot have another attempt for 20 years!  

The NHS Constitution goes on to say:

“Working together for patients

Patients come first in everything we do. We fully involve patients, staff, families, carers, communities, and professionals inside and outside the NHS. We put the needs of patients and communities before organisational boundaries. We speak up when things go wrong.

Respect and dignity.

We value every person – whether patient, their families or carers, or staff – as an individual, respect their aspirations and commitments in life, and seek to understand their priorities, needs, abilities and limits. We take what others have to say seriously. We are honest and open about our point of view and what we can and cannot do.

Here, we are told that the NHS values and respects every individual.  The NHS puts the needs of patients and communities before organisational boundaries.  It is apparent, however, that when one wants to get some text amended on the NHS Choices website, the editors defer to their advisors.  Thus, our request to remove the sentence “Do not use bottled water [for baby formula] because it is not sterile and contains too much sodium and sulphates” has been refused three times because the editors listen to their scientific advisors and to no-one else!

We have not been taken seriously!  We know that bottled water is not sterile, but neither is tap water.  Both must be boiled.  We know that bottled water contains sodium and sulphates but tap water contains both chemicals and often in greater concentration.  No bottled water currently on sale in the UK has concerning concentrations of sodium and sulphate. 

What is one to think about the scientific advisors employed by the NHS to police the NHS Choices web pages?  We know that the NHS is a sponsor of Water Fluoridation and perhaps, just perhaps, the advisor/s who make decisions about content on NHS Choices is/are the same as those who is/are pressing for a continuance/expansion of Water Fluoridation?

The Constitution is big on individual rights of patients but in the writing of the Constitution, the “patient” becomes someone who is actively being cared for as opposed to being a member of the public who is signed up with a GP but who is not currently being treated.  But that can’t be right.  After all, taxes and NI contributions pay for the NHS and if we are paying into the system then we are automatically customers of the system, i.e. we are patients.

In the slightly narrower sense of the word, “patient” is anyone who contacts of visits a GP’s surgery.  But the person could also be a patient when the surgery writes to invite them to have a flu or shingles jab.  From the moment you are referred to as the “patient” then the Constitution in its entirety applies to you. 

“Respect, consent and confidentiality Your rights. You have the right to be treated with dignity and respect, in accordance with your human rights. You have the right to be protected from abuse and neglect, and care and treatment that is degrading. You have the right to accept or refuse treatment that is offered to you, and not to be given any physical examination or treatment unless you have given valid consent. If you do not have the capacity to do so, consent must be obtained from a person legally able to act on your behalf, or the treatment must be in your best interests.” Involvement in your healthcare and the NHS Your rights. You have the right to be involved in planning and making decisions about your health and care with your care provider or providers. You have the right to be involved, directly or through representatives, in the planning of healthcare services commissioned by NHS bodies, the development and consideration of proposals for changes in the way those services are provided, and in decisions to be made affecting the operation of those services. You have the right to make a claim for judicial review if you think you have been directly affected by an unlawful act or decision of an NHS body or local authority. You have the right to compensation where you have been harmed by negligent treatment.”

Here again is the section which refers to public health:

“The Constitution applies to all staff, doing clinical or non-clinical NHS work – including public health – and their employers. It covers staff wherever they are working, whether in public, private or voluntary sector organisations. You should aim to: involve patients, their families, carers or representatives fully in decisions about prevention, diagnosis, and their individual care and treatment.”

The NHS Constitution applies to the Secretary of State for Health and Social Care.  He oversees the entire NHS healthcare system.  Part 1 of this paper established that fluoridated water is a medicine because that is what is claimed in the British Standard: “hexafluorosilicic acid is used for the fluoridation of drinking water to increase the resistance of consumers to dental decay.” It is NOT water treatment. 

The Secretary of State has the power to propose or terminate Water Fluoridation programmes.  He is the principal line manager for public health practitioners (including the Chief Medical Officer for England), who are encompassed by the Constitution.  They sponsor Water Fluoridation: they prescribe the treatment, a prophylaxis.  The prophylaxis is applied to entire communities without individual consent.

If you cannot afford to filter or purchase pure water, then the administration of the medicine is compulsory.  The NHS Constitution states that: “You have the right to accept or refuse treatment that is offered to you, and not to be given any physical examination or treatment unless you have given valid consent.”

https://www.gmc-uk.org/-/media/documents/prescribing-guidance-updated-english-20210405_pdf-85260533.pdf

The line of responsibility for observing the NHS Constitution is written into its provisions and pledges.  Thus, the Secretary of State for Health and Social Care right down through the ranks to ancillary staff in hospitals and GPs’ surgeries as well as NHS contractors must observe the patient’s right to refuse consent to treatment and medicine.    

The NHS cannot be viewed as a separate entity: public health (which administers Water Fluoridation), the NHS and the DHSC are all controlled by one person and that person has to observe the NHS Constitution.

If you have been spontaneously contacted recently by your GP’s surgery and have been offered a vaccination, that implies that you are a patient of the NHS even if you decide not to be vaccinated.  Therefore, the next section applies to you.  Much of the quoted text has been written for the instruction of GPs and hospital doctors.

All bolded text is our own emphasis.

Good practice in prescribing and managing medicines and devices

“16  In providing clinical care you must: (a) prescribe medicine or treatment, only when you have adequate knowledge of the patient’s health, and are satisfied that the medicine or treatment serve the patient’s needs.” ….

Sections 35-39 expand on 16 above.

35 Together with the patient, you should assess their condition before deciding to prescribe a medicine. You must have or take an adequate history, which includes:

(a) any previous adverse reactions to medicines

(b) current and recent use of other medicines, including non-prescription and herbal medicines, illegal drugs and medicines purchased online or face to face

(c) other medical conditions.

36 You should encourage your patient to be open about their use of alternative remedies, illegal substances and medicines obtained online or face to face, as well as whether or not they have taken prescribed medicines as directed in the past.

37 If you need more information to help you decide which options would serve the patient’s needs, you must ask for it before recommending an option or proceeding with treatment.

38 If it’s not possible to clarify or ask for more information from the patient in the environment you are working, you should consider whether it is safe to prescribe, and raise concerns as appropriate. For example, it may be appropriate to raise concerns if the system in which you’re working involves prescribing remotely on the basis of a questionnaire and there is no mechanism for two-way dialogue or communication with patients.

Assessing the patient’s needs

39 You should identify the likely cause of the patient’s condition and which treatments are likely to meet their needs.

40 You should reach agreement with the patient on the proposed treatment ⁽¹⁰⁾ explaining:

a the likely benefits, risks and impact, including serious and common side effects

b what to do in the event of a side effect or recurrence of the condition

c how and when to take the medicine and how to adjust the dose if necessary

d how to use a medical device

e the likely duration of treatment

f any relevant arrangements for monitoring, follow-up and review, including further consultation, blood tests or other investigations, processes for adjusting the type or dose of medicine and for issuing repeat prescriptions.

55 If you are the patient’s GP, you should make sure that changes to the patient’s medicines, for example following hospital treatment, are reviewed and quickly incorporated into the patient’s record. This will help to avoid patients receiving inappropriate repeat prescriptions and reduce the risk of adverse interaction.¹⁶

Reviewing medicines

93 Whether you prescribe with repeats or on a one-off basis, you must make sure that suitable arrangements are in place for monitoring, follow-up and review. You should take account of the patients’ needs and any risks arising from the medicines.

94 When you review a patient’s medicines, you should reassess their need for any unlicensed medicines (see paragraphs 103 to 106) they may be taking, for example antipsychotics used for the treatment of behavioural and psychological symptoms in dementia.

95 Reviewing medicines will be particularly important where:

a patients may be at risk, for example, those who are frail or have multiple illnesses

b medicines have potentially serious or common side effects

c the patient is prescribed a controlled or other medicine that is commonly abused or misused

d the BNF or other authoritative clinical guidance recommends blood tests or other monitoring at regular intervals.

96 Pharmacists can help improve safety, efficacy and adherence in medicine use, for example by advising patients about their medicines and carrying out medicines reviews. This does not replace your duty to ensure you are prescribing and managing medicines appropriately.

97 You should consider and act appropriately on information and advice from pharmacists and other healthcare professionals who have reviewed a patient’s use of medicines. This is especially the case if there are changes to a patient’s medicines, or if they report problems with tolerance, side effects or with taking medicines as directed.

Repeat prescribing and prescribing with repeats

98 You are responsible for any prescription you sign, including repeat prescriptions for medicines initiated by colleagues, so you must make sure that any repeat prescription you sign is safe and appropriate. You should consider the benefits of prescribing with repeats, and where possible, reduce repeat prescribing.

99 As with any prescription, you should agree with the patient which medicines are appropriate and how their condition will be managed, including a date for review. You should make clear why regular reviews are important and explain to the patient what they should do if they:

a suffer side effects or adverse reactions

b stop taking the medicines before the agreed review date, or before a set number of repeats have been issued.

You must make clear records of these discussions and your reasons for repeat prescribing.³²

100  You must be satisfied that procedures for prescribing with repeats and for generating repeat prescriptions are secure and that:

a the right patient is issued with the correct prescription

b the correct dose is prescribed, particularly for patients whose dose varies during the course of treatment

c the patient’s condition is monitored, taking account of medicine usage and effects

d only staff who are competent to do so prepare repeat prescriptions for authorisation

e patients who need further examination or assessment are reviewed by an appropriate healthcare professional

f any changes to the patient’s medicines are critically reviewed and quickly incorporated into their record.

101 At each review, you should confirm that the patient is taking their medicines as directed and check that the medicines are still needed, effective and tolerated. This may be particularly important following a hospital stay or changes to medicines following a hospital or home visit. You should also consider whether requests for repeat prescriptions received earlier or later than expected may indicate poor adherence, leading to inadequate therapy or adverse effects.

102 When you issue repeat prescriptions or prescribe with repeats, you should make sure that procedures are in place to monitor whether the medicine is still safe and necessary for the patient. You should keep a record of dispensers who hold original repeat dispensing prescriptions so that you can contact them if necessary.

There is even a section on prescribing unlicensed medicines:

106 When prescribing an unlicensed medicine, you must:

A  be satisfied that there is sufficient evidence or experience of using the medicine to demonstrate its safety and efficacy

B  take responsibility for prescribing the medicine and for overseeing the patient’s care, monitoring and any follow up treatment, or make sure that arrangements are in place for another suitable doctor to do so

C  make a clear, accurate and legible record of all medicines prescribed and, where you are not following common practice, your reasons for prescribing an unlicensed medicine.

Fluoridated water is an unlicensed medicine.

The seven principles of decision making and consent

 Published 9 November 2020

One

All patients have the right to be involved in decisions about their treatment and care and be supported to make informed decisions if they are able.

Two

Decision making is an ongoing process focused on meaningful dialogue: the exchange of relevant information specific to the individual patient.

Three

All patients have the right to be listened to, and to be given the information they need to make a decision, and the time and support they need to understand it.

Four

Doctors must try to find out what matters to patients so they can share relevant information about the benefits and harms of proposed options and reasonable alternatives, including the option to take no action.

Five

Doctors must start from the presumption that all adult patients have capacity to make decisions about their treatment and care. A patient can only be judged to lack capacity to make a specific decision at a specific time, and only after assessment in line with legal requirements.

Six

The choice of treatment or care for patients who lack capacity must be of overall benefit to them, and decisions should be made in consultation with those who are close to them or advocating for them.

Seven

Patients whose right to consent is affected by law should be supported to be involved in the decision-making process, and to exercise choice if possible.

https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/decision-making-and-consent/the-seven-principles-of-decision-making-and-consent

If a licensed or non-licensed medicine is prescribed by a GP to a patient of the NHS, the GP must review the continuing advisability for the patient to take the medicine.  Each licensed or non-licensed medicine is tailored to the patient’s individual circumstances: age, weight, gender, medical history and other medicines currently being taken. 

The fluoride added to drinking water is a medicine and if the GP asks the patient what medicines they are currently taking, the patient ought to feel able to tell the GP that they are taking  1mg fluoride twice a day in 2 litres of water.  Many GPs would be incredulous about this information because the public and medical profession are not encouraged to view fluoride in drinking water as a medicine.  However, public perception does not seem to form part of the NHS Constitution and medical ethics.  The GP ought to be reminded that he is authorised to prescribe unlicensed medicines and the fluoride in drinking water is no different to any unlicensed medicine he might choose to recommend to the patient, apart from its compulsory nature and its lifetime duration.  It is never reviewed.

Unlicensed medicines recommended by the GP are controlled by the rules controlling the  prescribing of medicines.   Unlicensed medicine added to drinking water by order of the Secretary of State and public health should be controlled by the rules controlling prescribing of medicines, otherwise the State could start to order the addition of other undesirable substances to drinking water.  There have already been murmurs by scientists wanting to add statins and lithium to drinking water to control “bad” cholesterol and schizophrenia respectively. 

Those who support water fluoridation would be quick to point out that whereas GPs and other medical doctors are covered by the rules controlling the prescribing of medicines, the Secretary or State and Public Health Consultants are not medical doctors and that the prescribing rules do not apply.  This observation can be countered by reminding them that the Chief Medical Officer for England is a registered doctor on the specialist register with the GMC.  Chris Whitty qualified in 1991 with a BM BCh from Oxford University and was registered with the GMC on 15^th July 1991.  His speciality is tropical infectious medicine.

Here is his career biography:

Whitty is a practising National Health Service (NHS) consultant physician at University College London Hospitals (UCLH) and the Hospital for Tropical Diseases, and Gresham Professor of Physic at Gresham College, a post dating back to 1597.[2][10] [11] Until becoming CMO he was Professor of Public and International Health at the London School of Hygiene & Tropical Medicine (LSHTM) where he was also Director of the Malaria Centre.[12] He worked as a physician and researcher into infectious diseases in the UK, Africa and Asia. In 2008 the Bill & Melinda Gates Foundation awarded the LSHTM £31 million for malaria research in Africa. At the time, Whitty was the principal investigator for the ACT Consortium, which conducted the research programme.[3][13]

  (Wikipedia, https://en.wikipedia.org/wiki/Chris_Whitty )

Chris Whitty is pro-fluoridation.  He strongly advocates prescribing fluoride for the entire population of England and Wales.  He knows full well the necessity for a medical doctor to review the continuance of medicine for patients. He should be asked to justify sponsoring the administration of a medicine to people for a lifetime who have no need for it, especially if they have none of their own teeth.  Chris Whitty’s senior officer is the Secretary of State for Health and Social Care and both have a responsibility to observe the NHS Constitution.

“It is concluded that the status quo rests on the legal fiction that fluoridated water does not constitute a medication.” (Shaw, 2012). 

Fluoridated Water Is A Medicine

Reference :  Shaw, D. (2012) Weeping and wailing and gnashing of teeth: The Legal fiction of water fluoridation.  Medical Law International 2012 12: 11.

The entire practice of water fluoridation depends on the Government, the NHS and Public Health denying that fluoride is a medicine.

How can that be?  Fluoride is added to drinking water” to increase the resistance of consumers to dental decay”.  (BSEN 12175:2022, p.19)  Its function/intention is as a prophylactic.  It doesn’t matter whether it works or not: that consideration is immaterial.

The mantra that fluoride is “safe and effective” is also immaterial.  It could be the safest thing on this planet BUT that doesn’t alter the fact that it is administered 24/7, 52 weeks of the year for a lifetime.  Moreover, it is not indicated for adults, and especially for those who have no teeth.  It is administered at the behest of public health practitioners and approved of by the Secretary of State who doesn’t have a medical qualification.

Medical ethics state that medical practitioners who prescribe licensed and un-licensed medicine should have regard to a patient’s age, gender, health condition, other medicines and the need to continue on that medication.  The requirement to review the medicine is written into medical ethics.

The NHS Constitution applies to all people who work for the NHS, for public health and service providers.  The Secretary of State must also observe the Constitution.

“The Secretary of State for Health, all NHS bodies, private and voluntary sector providers supplying NHS services, and local authorities in the exercise of their public health functions are required by law to take account of this Constitution in their decisions and actions.” And … … “References in this document to the NHS and NHS services include local authority public health services …”

Before moving to the final part of this paper, the reader is advised to access a paper entitled Fluoridation: A Violation of Medical Ethics and Human Rights

In 2007, the Nuffield Council on BioEthics was asked to review the practice of Water Fluoridation.  Their conclusions were:

“The acceptability of any public health policy involving the water supply should be considered in relation to: the balance of risks and benefits, the potential for alternatives that rank lower on the intervention ladder to achieve the same outcome and the role of consent where there are potential harms The most appropriate way of deciding whether to fluoridate the water supply is to rely on democratic decision-making procedures. These should be implemented at the local and regional, rather than national level because the need for, and perception of, water fluoridation varies between areas.”

We advise a read of the Nuffield paper from p. 123 – 139 in the first instance.
Nuffield Council on BioEthics (2007) Public health: ethical issues

If we are to defend our stance of “my body, my choice”, then the chapter on WF in the Nuffield Committee on Bioethics Report can be completely discounted.  However, Nuffield mentions in several places that the issue of consent cannot be contemplated in view of the universality of WF.  It would be impossible to canvass every individual to determine the degree of opposition:

“Is the intervention justifiable even if it is not possible (or feasible) to obtain individual consent?” (p. 121, Section 7.1)   “However, because of the nature of the intervention it is not possible to provide each individual affected with a choice. This is both because its implementation across whole areas means that it would not be possible to accommodate the differing choices of every individual in that area, and because people from outside the area who visit or move there after its introduction would be affected by the measure. Considerations about consent could hence be used to argue that the measure should not be introduced either where some individuals, however few, were opposed to it, or where individuals who had not agreed to it might be affected by it, such as those from outside the area. However, this would presuppose clear evidence about risks of harms and in the absence of such evidence give too much weight to the importance of choice and consent, allowing them automatically to override any collective good that might be achieved through the measure.” (p. 129, Section 7.20)

Missing the wood for the trees:  if choice cannot be offered in respect of a medicinal intervention, then it is not advisable to contemplate putting the measure in place.

According to Nuffield, considerations over consent would be more justifiable where harm is demonstrated. On the other hand, considerations over consent should not override the desire for achieving the collective good where relatively few people are opposed and where there is no strong evidence of harm being caused by the intervention. Did the Nuffield Committee lose the plot at this juncture?  Were they more concerned with social science than with human rights?  Had they completely forgotten that Water Fluoridation was an experiment without individual consent which violates the Nuremberg Code 1947? And finally, was the Committee aware that Water Fluoridation is powered by industrial and political vested interests? Nuffield also seemed to be unaware that individuals react in different ways to chemicals: “what is good for the goose may not necessarily be good for the gander”.

Nuffield wrote its report in 2007.  Sixteen years later, robust studies have demonstrated great harm:  harm to the developing brain and harm to our bones.  Harms which are experienced more acutely by people living in other countries where drinking water contains unacceptable concentrations of fluoride. Both harms have been known about for many years but only now do we have conclusive reproducible proof against WF Practice.

In the past few years, a review of 85 studies on fluoride’s effect on human intelligence by the USA’s National Toxicology Program (NTP) has concluded that “fluoride is a presumed developmental neurotoxin”.  On 15^th March 2023 we finally received confirmation that “fluoride can cause a reduction in intelligence”. We now expect Judge Edward Chen in the USA to schedule a final hearing during 2023 on the issue.

Also, in April 2021, a strong study from Sweden (Helte et al) found that there were 50% more diagnoses of hip fracture in elderly women in a natural fluoride area compared to an area with little or no fluoride in its drinking water.  That result can be applied to England and we are impatient for the National Institute for Health Research to initiate a study.  It has been known for decades that fluoride stores in our bones and causes a disruption to osteoclasts, osteoblasts and collagen so it should come as no surprise that easily fractured bones are a result.

The research base is also strong in relation to fluoride’s damage to the endocrine system.

One of Nuffield’s conditions for reviewing a practice is to balance risks and benefits.  The balancing exercise is a purely subjective one and it appears that individuals are not likely to be consulted to determine what they consider to be the determinants for deciding on the balance between avoiding harm of any sort and endeavouring to prevent dental decay. 

We have now reached this thorny issue yet again but this time we approach it from Nuffield’s point of view.  This is what Nuffield has to say on the topic:

Box 7.6: Fluoridated water – food or medicinal product   Several respondents to our consultation raised concerns over whether fluoridated water was a fortified food or a medicinal product, and where this fitted within the regulatory system in the UK. The legal situation is that while in principle drinking water is considered a food, the addition of fluoride is not considered a food supplementation process. This is because, from a legal viewpoint, water provided by the local water supply is only considered a food once “it emerges from the taps that are normally used for human consumption”,57 and because water is not considered a food at the point at which fluoride is added, the process is not considered supplementation of food.58   The UK Medicines and Healthcare Products Regulatory Agency (MHRA), which licenses medicinal products in the UK, has indicated that fluoridation of water is not within its remit: “As drinking water is quite clearly a normal part of the diet the MHRA does not regard it to be a medicinal product.”59 Fluoridation of water at the water treatment stage also does not fall within the remit of the Food Standards Agency as a fortified food, because it is not legally considered to be such a food, as outlined above.60 However, this is not to say that the content of drinking water is unregulated, because it is covered by legislation on water quality, which includes levels of fluoride and processes for implementation of fluoridation. Drinking water safety and quality, including the water fluoride level, is checked by the UK Drinking Water Regulators.61 Policy on water fluoridation is determined by the Department of Health in England, the Welsh Assembly Government in Wales and by the Scottish Executive in Scotland.62

This following graphic is our view of the situation:

Treated Drinking Water   >     Fluoride Added   >      Emerges from taps  >    Medicine

To repeat the legal interpretation: it is not illegal to add hexafluorosilicic acid to treated water because water is not considered a food at the point at which fluoride is added, so the process is not considered supplementation of food. This is much like arguing a legal point on the point of a needle!  The point of compliance (to drinking water guidelines) is the kitchen tap.  That’s all very well, but if it is not drinking water which comes out of the tap but a medicinal liquid which does not comply with the Drinking Water Directive, then there are no guidelines which can be applied, and the consumer is not protected if harm is caused by fluoride or any other toxin or pathogen present in the medicinal liquid as it comes out of the kitchen tap.

Another interesting point of law:  it is not permitted in law to add hydrofluoric acid to treated water so the process of adding hexafluorosilicic acid (which contains hydrofluoric acid) is illegal.  In other words, it is not permitted in law to add hexafluorosilicic acid to treated water because in so doing, hydrofluoric acid would be added. (Water Industry Act 1991, s.87)

The question must be asked:  if it is not admitted by the authorities that it is a medicine, then why is fluoride added to treated water?  If no other answer can be provided, then it can only be medicine.  It cannot remain in a vacuum. For that matter, why is fluoride added to milk and salt if it is not intended to have a physiological effect on developing teeth?

On the other hand, the MHRA considers fluoridated water to be food. If that is the case, it’s a dilute solution of hexafluorosilicic acid which is not permitted to be added to food during manufacturing processes.  In this respect, Nuffield missed the point altogether.  It may not intentionally be added by manufacturers to food ingredients in the manufacturing process but that doesn’t alter the fact that the diluted acid is added to food.  It is the act and not the intention which is the clincher: its presence in food is not allowed whether its presence was intentional or deliberate.  So,

Tap     >     Diluted solution of hexafluorosilicic acid     >    Used to manufacture food which                                                                                                                                   is not permitted in law

The legal authorities are:

EU Reg 1925/2006, Article 17

EU Reg 1170/2009, Annex III.  This Annex permits sodium fluoride and potassium fluoride but not hexafluorosilicic acid

UK Reg. 1631/2007.  This Reg. transposed the EU Regs into UK Law.

A barrister for the respondents might try to argue that fluoride is in tea leaves.  Is Indian tea to be regarded as being illegal?  It would be difficult to argue its illegality because fluoride was in the leaves prior to being picked and nothing has been added during the fermentation process. Tea drinking is a voluntary practice whereas drinking treated water is not because we pay for it and we need to be hydrated.

     

Now, Nuffield observes in the References below at (63), that few people would wish to have natural calcium fluoride removed from their drinking water.  We take exception to that statement because (a) Hartlepool receives drinking water containing 1.3 mg fluoride/litre and that is far too high, and (b) since even concentrations of 0.2 mg fluoride/litre have the potential to reduce intelligence by an IQ point, once people learn about this, they would most certainly want to have natural fluoride removed during water treatment.

References for the inset text above

  57 Regulation (EC) No. 178/2002 of the European Parliament and of the Council laying down the general principles and requirements of food law, establishing the European Food Safety Authority and laying down procedures in matters of food safety, available at: http://europa.eu.int/eur-lex/pri/en/oj/dat/2002/l_031/l_03120020201en00010024.pdf;

Council Directive 98/83/EC on the quality of water intended for human consumption, available at: http://europa.eu.int/eur-lex/pri/en/oj/dat/1998/l_330/l_33019981205en00320054.pdf.

 

58 Several respondents to our consultation raised concerns about the currently used source of fluoride for water fluoridation, fluorosilicates, not being included in the list of permitted vitamins and minerals for food supplementation that is found in EU legislation. Some suggested that this meant that fluoridation by this means was illegal; however, as described in the text above the process is not legally considered to be supplementation of food. Regulation (EC) No 1925/2006 of the European Parliament and of the Council of 20 December 2006 on the addition of vitamins and minerals and of certain other substances to foods (see Annex II), available at: http://eur-lex.europa.eu/LexUriServ/site/en/oj/2006/l_404/l_40420061230en00260038.pdf.  

59 Personal communication, MHRA.  

60 Personal communication, FSA. Furthermore, the FSA’s Expert Group on Vitamins and Minerals concluded that drinking water and dental products containing fluoride were “neither foods or food supplements”; Expert Group on Vitamins and Minerals (2003) Safe Upper Levels for Vitamins and Minerals (London: Food Standards Agency), available at: http://www.food.gov.uk/multimedia/pdfs/vitmin2003.pdf.  

61 This includes the Drinking Water Inspectorate for England and Wales, the Drinking Water Quality Regulator for Scotland and the Drinking Water Inspectorate for Northern Ireland. For further information see: Drinking Water Inspectorate, Fluoridation of Drinking Water, available at: http://www.dwi.gov.uk/consumer/concerns/fluoride.shtm.  

62 Department of Health, Oral Health, available at: http://www.dh.gov.uk/en/Aboutus/Chiefprofessionalofficers/Chiefdentalofficer/DH_4138822; Welsh Assembly Government, Information Briefing on Fluoridation, available at: http://new.wales.gov.uk/topics/health/professionals/dental/oralhealth/programmes/fluoridation/?lang=en; Scottish Executive (2002) Towards Better Oral Health in Children, available at: http://www.scotland.gov.uk/consultations/health/ccoh.pdf.  

63 However, few people would probably follow up this argument by maintaining that naturally occurring fluoride should be removed from water supplies in areas where this occurs at low levels.   

Footnote 63 refers to:

7.21 Another argument that might be made against fluoridation is that, although individual consent may not be required, the intervention could be seen to restrict the choices of individuals in some significant way (see paragraphs 2.19, 2.44), because individuals are able to exercise little choice over the water they consume. Fluoridation might thus be seen to interfere with important values of personal life, but the precise nature of these values may not always be clear. For some, the value may relate to being able to have a choice about what to ingest.⁶³ For others, the value may be about a certain conception of health, or water may be considered to be ‘special’. For example, some respondents to the consultation suggested that water could be regarded as intrinsically pure and natural, or as a public good that should be provided in as ‘neutral’ a form as possible (see Box 7.7). “

We agree that it should be in as “neutral” a form as possible with nothing added for our health but with undesirables removed.  That is what most of us pay the majority of water companies for.

For too many years, we have been convinced by health authorities that fluoride is safe to swallow when there has been no proof whatsoever.  Hexafluorosilicic acid and fluoridated water has never been clinically tested during randomised trials. Neither has it been licensed as a medicinal product and here have been no high quality studies into its safety or otherwise.  This failure to provide proof is probably because pro-fluoridation governments do not want to learn the truth.

Another proof which is denied is the medicinal nature of fluoridated water.  Its desired function is as a prophylactic so it can be nothing other than a medicine.  Industrial hazardous waste containing fluoride is added to drinking water “to increase the resistance of consumers to dental decay”. 

The fluoridating acid contains numerous heavy metals, including arsenic.  There can be no excuse whatsoever to deliberately add arsenic to treated water: it’s a carcinogen. In short, any amount of arsenic in fluoridated drinking water is too much. When the adulterated water emerges from the kitchen tap, it’s not drinking water so the drinking water guidelines cannot apply even though the Drinking Water Inspectorate (DWI) puts on a brave face and maintains that it is drinking water. Nuffield completely overlooked this distinction and that would appear to invalidate its report.

We are told that adding fluoride to treated water is for the common good.  It would still be wrong to do so even if it was wholly beneficial.  However, it is not beneficial: not only is it not a nutrient but the body has no effective way of utilising the chemical.  If it can’t be excreted, it must be sequestered out of the way in bones and teeth. Unfortunately, it also stores in the pineal gland and thyroid gland.  In all cases where it is stored in the body, it eventually causes harm, mainly in the long-term. Fluoride’s non-essentiality is another aspect overlooked by Nuffield.

The pro-fluoridation ethical viewpoint can only be entertained if fluoride was harmless. Even if it was harmless, it would still be a bridge too far because it is a practice which adds a chemical to treated water when no other substance can be added for our health benefit.

Chlorine or chloramine is water treatment so is in a different category.  It would be ideal if magnesium could be added but that is not permitted, even though indicated for good oral health.  So, it is confusing for the layman to comprehend why a soup of chemicals should be added, especially when all apart from selenium and a few other chemicals in the industrial scrubbing liquid, are injurious.

The conclusion of our paper is that although the practice of water fluoridation is claimed by Nuffield to be a “collective good”,  that cannot be established, especially now that we have had it confirmed on 15th March 2023 that “fluoride can cause a reduction in intelligence”. It is therefore, a developmental neurotoxin.

Disclaimer: Nothing in this paper should be taken as constituting legal of medical advice.