Ethics in Radiological Protection for Medical Diagnosis and Treatment

Draft document: Ethics in Radiological Protection for Medical Diagnosis and Treatment

Submitted by Christopher John Kalman, Retired, Hon Sen Lect in Public health medicine University of Glasgow
Commenting as an individual

Title. The definitions of radiological protection (RP) centre on the protection of people and the environment from the harmful effects of ionising radiations. This paper’s title indicates it deals with ethics of RP for Medical diagnosis and treatment. However in fact its consideration is entirely limited to protection of patients in relation to these aspects. This requires action either to amend the title stating the limitation to patients, or to enhance the paper by the full consideration of RP in medical irradiation. In my view there has been a recent and disturbing tendency in some countries to consider healthcare safety and patient safety to synonymous terms. Please do not allow the ICRP to follow suit. No sensible consideration of healthcare safety culture can consider patient safety in isolation. In relation to ionising radiations there are complex occupational situations with ethical considerations, for example in terms of the incidence of tissue reactions in interventional cardiology, or PET scan manufactures indicating that dose control and constraints can only be achieved by employing more radiographers and dose sharing. In terms of the environment, almost all of the legal approved radioactive discharges in major cities and population centres result from the need for medical use, and there are complex issues regarding other patients, staff, members of the public and close family exposed by contact with active patients.

ICRP 138 was of huge importance, though in many ways it is a retrospective document looking at ethical considerations within the evolution of the Commissions development of radiation protection control systems decades. These systems of course become the basis of RP regulation in the majority of the world, and hence 138’s basis is the ethics of the development of this regulation. If there is a need to extend ethical considerations in to day today RP dealing with exposure to an individual or a group, there is a need to review 138, looking at the importance to factors such as empathy, which has little place in regulation. The paper does this, but purely justified in terms of patients, however surely it must be at least of equal importance in more general day to day RP dealing with occupations or the environment.

Radiation is one of many modalities of health intervention, either in terms of diagnosis or treatment. As the paper makes clear, biomedical ethics is a mature field which has operated and developed over generations. The paper also makes clear that in medical irradiation, biomedical ethics is already firmly in place. On this basis, as a single modality amongst many, the question should be asked whether there is any justification or place for radiation specific ethics, or whether it would be better simply to consider radiation of patients in healthcare as being subject to the requirements of a system of biomedical ethics covering all of health related practice. If there is such a justification, surely it must be stated in the paper, indeed it would represent the justification for its publication. If such a justification does exist, it is unlikely to be based on acute and chronic hazards that can be local or distant, or indeed complex toxicology. Some of the factors considered in 1 above in terms of none patient factors may however be relevant.

I would suggest there are some potential factors in biochemical and radiation ethical issues which could be covered in greater depth, these include;

i. Emergency response or the need for speed in both decision and action. It is noted in relation

Implementation of early urgent countermeasures following radiological accidents, radiation

protection practice already has an example of different ethical decisions in an emergency

situation

ii. Societal v individual benefit. Biomedical ethics allows immunisation of individuals with little

or no risk of mortality, to protect those at risk; eg. Whooping cough vaccination of 2 year olds.

iii. The concept of realistic medicine. Which is perhaps the logical endpoint of some of the

papers discussion of empowerment.

iv, Resources. On a world scale healthcare is invariably practiced with inadequate resources in

terms of equipment staff and training. This is a common finding in radiation aspects of

medicine. There is scope to consider this specifically in the paper.

5. Some like Nicolas Foray actively involved in the field have adopted the nomenclature of

radiosensivity to tissue reactions from treatment, and radiosuceptability for radiation induced

second cancers, and indeed in relation to occupational risk. I think this system has some

merit. Given the potential importance of development in this area I suggest the paper needs

further discussion here and I could not agree that current radiosensivity testing clinically is

limited to monogenetic disorders. The issues must at least be include as a risk “we do not yet

fully understand”

6. I think I have some understanding as to why spoof names were used for case examples in the

draft, however I would advise their removal. Firstly they are very Western orientated and it is

important that the paper is thought off as universal in ethical derivation. Secondly despite

their spoof nature there are probably huge numbers of actual people with similar names who

could take offence and indeed legal action. I would certainly suggest some legal advice before

publication if they are to be retained

7. A number of the cases relate to actions by none radiation professionals. Case also include,

almost as an absolute statement, the results of ethical considerations of other modalities.

Surely the phases “not an option “or “not viable” are the end stages of an ethical evaluation of

another modality. Is not the actual requirement here for there to be some combined evaluation

aware of the potential detriments of all modalities rather than passing patients on to another

specialty purely on the basis of single modality assessments.

8. Given my previous comment on lack of resource, for inclusiveness and to enhance relevance

it is suggested that there should be examples of isolated rural deprived practice.

9. An important and universal aspect of RP is the need for local rules as the mechanism of

delivering effective radiological safety. Should not the paper make mention of the delivery of

Ethical practice by compliance with these rules. In fact some of the examples would not arise if

appropriate rules were in place. This fits well with the papers use of Taxonomy of Learning with

staff trained to the Understanding level undertaking ethical practice based on local rule

compliance.

10. The paper spends some time discussing RP training, without any further definition, other than

recommendations to include some consideration of ethics. In my view the RP training can be

usefully divided into 3 for almost all people involved. Crucially it needs to include the hazard.

This in my experience is often omitted in worker training, though I think worker’s compliance

with protection requirements is much better if they have a sound hazard knowledge, secondly

training should include the basics of principles of RP, before moving on to the specifics of RP

for this particular practice in this particular situation and circumstance. The paper is now

suggesting an additional element related to ethics, but it is only relevant if knowledge of all 3

of the other aspects is satisfactory.

11. Of crucial importance is the ability to provide risk information to patients in relation to their

proposed care. This involves both the knowledge of the staff member, and their ability to

communicate. As indicated in many areas involving ionising radiations there are uncertainties.

While those involved in radiation medicine probably all follow statutory regulation

requirements in their practice, in my experience there is no unanimity of view in relation to risk

to their patients of such practice. This makes effective ethical provision of information difficult.

Perhaps the most effective way forward is for the production at international level of patient

information briefings on risk of procedures use of which are mandatory.

C J KALMAN. June 2023

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