Ethics for Radiation Protection in Medicine

Jim Malone, Friedo Zölzer, Gaston Meskens, Christina Skourou

• Editorial: CRC Press
• Año: 2018
• ISBN:
  9781351372480
• Edición: 1
• Categoría: Medizin
• Categoría: Onkologie

• An authoritative and accessible guide, authored by a team who have contributed to defining the area internationally
• Includes numerous practical examples/clinical scenarios that illustrate the approach, presenting a pragmatic approach, rather than dwelling on philosophical theories
• Informed by the latest developments in the thinking of international organizations

CHAPTER 1

Introduction

1.1 INTRODUCTION

Radiation is a significant positive contributor to modern healthcare and is used for both diagnostic and therapeutic purposes. The diagnostic applications are for the greater part in medical imaging, within which the most frequently used modality is radiology. For example, multislice computed tomography is a highly successful and widely available technique. The therapeutic interventions are mainly, though not exclusively, in radiation oncology. Both have greatly enhanced the effectiveness of medical practice and have overseen technology transfer on an exceptional scale into the healthcare system, in a relatively short time (ICRP 2007b).

The World Health Organisation (WHO) definition of health as a state of complete physical, mental and social well being is broad, including ethical, social, public health and resource considerations (WHO 2006). Accepting this definition requires that we look at the societal background to the radiological protection system as part of establishing an ethical framework suited to its application in medicine. The radiation protection system is based on a mixture of scientific evidence, practical experience and value judgements and has an ethical dimension that until recently has not been explicitly stated (ICRP 2018). In medicine, the principles of the International Commission on Radiological Protection (ICRP) (i.e. justification, optimisation and dose limitation) must be implemented in light of the values generally informing medical practice and ethical behaviour in society.

However, the benefits of radiation come at a price, and its range of application now accounts for over 98% of man-made human radiation exposure, which is accompanied by an increased population radiation burden and associated probable risks. Every day more than 10 million diagnostic procedures are performed globally, amounting to some 3–4 billion annually (ICRP 2007b; UNSCEAR 2012). Similarly, 7 million cancer patients may benefit from radiotherapy globally each year (Jaffray and Gospodarowicz 2015). The increase in dose and risk can be acceptable when a real benefit flows from it, such as improved diagnosis, a better treatment outcome, or better management of the patient. However, this is not always the case and patients can receive significant exposures, without receiving any information, and sometimes without commensurate benefit. For many years, diagnostic radiation dosage was regarded by many as a non-issue, but this is no longer acceptable (NCRP 2009).

1.2 SOCIETAL ISSUES AND THE HEALTH SECTOR

Medical practice and medical imaging necessarily take place within the context of the general developments in society and the expectations of its citizens. This, and its consequences for radiation protection in the medical sphere, have been reviewed at some length elsewhere. A few of the more important points are summarised here. First, it is important to be aware of the scale of resource allocation to healthcare, consuming as it stands 10%–20% of national budgets in many countries (Papanicolas et al. 2018). This alone would set it aside as an area of special concern from both practical and ethics viewpoints. Here, it is important to note that the historical paternalism of the medical professions no longer provides an acceptable approach to service delivery and interpersonal behaviour within the services. There are many other shifts in basic values and social concerns.

Here is a short list of societal areas in which there has been profound change since the principles on which the ICRP operates (ICRP 1966, 1977, 1991) were formulated and introduced: marriage, divorce, single parents, gay marriage, disability rights, gender rights, distrust of authority/professions, the right to life, euthanasia/assisted suicide in some jurisdictions, the dominant presence of social media, and widespread acceptance of the right to privacy/autonomy of the individual. In many cases, these changes are reflected in the law, social policy, and practices of society. This is particularly so in medicine where there have also been substantial shifts in practice, often driven by social or legal developments and often initially resisted by the health professions. In particular, there have been significant developments around the areas of patient status and consent (Malone 2008, 2009; Malone et al. 2009). It is thus evident that the principles of radiation protection must be applied in a healthcare system shaped by social forces that had little impact a few decades ago.

While the spend on healthcare is greater than before, the impact of health economics and special interest groups on decision making has become very important and can, on occasions, override real medical priorities and individual clinical decisions. Interest groups may divert resources to benefit their group; health professionals may be under pressure to optimise revenue; bureaucracies, including regulatory agencies, can be self-serving to the detriment of common good; and politicians need to deliver for the public at large (e.g. a local mammography screening programme). These problems and many more have given rise to a more formal approach to Health Technology Assessment (HTA). Arising from such studies there is now, in the wider literature, a strong evidence base for the view that in some countries there is significant over-utilisation of imaging (IAEA 2011; Papanicolas et al. 2018) and new radiotherapy technologies (Curry et al. 2014; Hager et al. 2015).

In addition, there is the ever-present issue among the public and other professions, of the risk(s) of radiation, real or imagined. The starting point for such discussion must be that radiation is a known carcinogen. How this impacts specific situations in diagnostic imaging or radiotherapy is the subject of the following chapters. For the moment, some brief comments are in order. The American College of Radiology (ACR) ‘White paper on Radiation Dose in Medicine’ suggests that current imaging rates may result in an increased incidence of radiation-related cancer in the near future. Some estimate the increase could be up to 1.5% or 2% (BEIR VII 2006; Amis et al. 2007). Of course, if the scan is necessary in serious or life-threatening situations, it must be done. (Malone et al. 2012; Semelka et al. 2012).

Estimates of deaths and future cancers in many publications hide notable uncertainty about their origins, significance and how they might be presented to patients and other health professionals. For example, the importance of a risk of a few per cent of deaths occurring 10 years into the future will be seen very differently by a young mother and by an octogenarian man with multiple pathologies. Likewise, there are great differences between the way risks are calculated and the way the benefits are estimated; frequently, it is a matter of apples and oranges, rendering it almost impossible to do real risk benefit estimates. Similar considerations may apply to comparisons with risks and benefits from other treatments/procedures and/or medications. We will return to these topics time and time again throughout the book.

Another important related area in which the prevailing environment has radically altered since the introduction of the present system of radiation protection in the 1960s, is in the openness, accountability, transparency and honesty that is now expected of medical professionals and the institutions in which they serve. This is obviously different in different parts of the world (Malone and Zölzer 2016; ICRP 2018). However, the direction in which external pressures are applied is invariably towards more openness, accountability and transparency. Likewise, in terms of the view of the person, there is now a high level of consensus in most political, social and legal systems respecting the dignity of individuals, their autonomy and their right to respect. All the above, and other obligations that will be discussed in later chapters, impose new burdens on professions not accustomed to this type of expectation and/or oversight (Malone and Zölzer 2016; Parsa-Parsi 2017).

Where these new expectations are not met and when, consequently things go seriously wrong in medicine in general, enquiry may initially follow a peer review-like process. In the past, where this failed, enquiry by a professional body often yielded acceptable results. However, it is now common for the findings of such a group to be regarded as unsatisfactory and self-serving. When this is the case, formal (often judicial tribunals of enquiry) follow to determine the pertinent matters of fact, which are sometimes pursued through the courts of law to confirm the facts and assign guilt/punishment. This has now become a common and accepted feature of the lives of health professionals (Malone et al. 2012).

1.3 CULTURE AND PROFESSIONS

The framework or ‘culture’ within which professionals operate may be considered from a point of view often taken by anthropologists, ethnographers or social scientists. In the nineteenth and early twentieth centuries, it was common for anthropologists to visit ‘newly discovered’ countries and/or tribes and report on the ways of life and the different cultures they encountered. This approach has been extended to subgroups of western society by social scientists, ethnographers and anthropologists. We are familiar with way-of-life studies and culture of disadvantaged subgroups. However, similar methodology can be applied to any identifiable group to expose the culture within which it operates. The group might be, for example: clerics, doctors, software engineers, or other professionals, including radiation protection specialists (Malone et al. 2012).

In these studies, the term culture is much broader than implied when it is used to denote some aspects of the arts. Wilson (2008), in a study of the decline of a highly identifiable group (clergymen), describes culture as follows:

[It] involves very concrete patterns of behaviour and ways of thinking that give shape to a particular body of people–whether we can put names on those features or not… It has its shape because of a deep and commonly held set of standards and expectations which come to expression in the behaviours of the collection of players… Living out a culture, with its innumerable assumptions and expectations, inevitably evokes in us a challenge when we come face to face with persons operating in a different one: we find it difficult to understand their behaviour because we don’t know where it is coming from.

The expected attitudes and behaviours of [those involved in] a particular culture can be so powerful that it becomes all but impossible for its members to even conceive of other ways of being.

Finally, cultures cling to existence tenaciously, for at least two reasons… The first lies precisely in the fact that much of their causation is unacknowledged. The second… lies in its capacity to generate meaning… For the individual who risks acting out a different paradigm, the cost in terms of rejection by the players who want to continue with the reassuring story may be high.

These characteristics can be applied to many groups, including physicians, radiologists, radiation protection professionals, regulators and the general public. Each group has, to some extent, the characteristics described by Wilson and many other thinkers in the area. The individual may be a member of one or more of these groups and while functioning as a member of that group will adopt the norms and approaches of the group, i.e. will live according to the culture of the group. Obviously, there are great advantages in a profession in having a healthy, responsive culture. This has been recognised in radiation protection, and the IRPA have issued a guide to developing the culture of radiation protection, including its positioning in society and among all the relevant stakeholders (IRPA 2014). In terms of effectiveness, the law is helpful in achieving the objectives of radiation protection, but a good culture may well be better.

1.4 RADIATION IN MEDICINE

Modern medical practice is so multifaceted that it defies a comprehensive description. Perhaps one defining characteristic is its immense scientific and technological success coupled with an iconic repositioning in public consciousness. Instances of medical progress are too numerous to mention, but examples include: minimally invasive surgery, cardiac interventional procedures such as stenting and electrophysiological treatments, and pain medicine injection techniques often requiring significant radiation commitments. Such progress has been accompanied by a growth in the public expectation of hospitals and medical institutions, to a level that is probably unrealistic and places an undue burden on the system and those working in it. This also, inevitably, creates public disappointment and anger when expectations are not met (Malone 2008; Malone et al. 2009).

A simpler measure of the importance of medicine in the life of a country is, as already noted, the scale of investment in both financial and human terms. In socialised systems it can become one of the largest items of government expenditure, and a corresponding component of the working lives of a large fraction of the population. Investment on this scale can only occur when the community regards it as important. Indeed, it has been argued that it is an iconic activity in which the public invests much of its hope and its aspirations to care both for itself and for others, when such care is needed. Thus, modern healthcare is an important part of the culture in which we live our lives.

This view of medicine as an iconic activity in society is further attested to by the number of medical soap operas that appear on television (see Table 1.1). When human societies do not fully understand what is happening in an area, they often create and tell stories that carry some (or all) of the meaning that cannot be articulated in a more conventional context by management and policy makers. The position of medical television soaps reflects this deep characteristic, our flawed understanding of the healthcare system, and our expectations of it. The last entry in the table is the cult soap ‘Green Wing’ in which a radiologist is one of the lead characters. Further light is thrown on this by both the engagement with art in modern hospital buildings and by the explicit targeting of health issues in some contemporary art, such as that by Damien Hirst.

TABLE 1.1 Ten Popular Medical Soaps (from 2017 listings)

• Grey’s Anatomy • Code Black • ER • Casualty • Doc Martin

• General Hospital • Holby City • The Doctors • House • Green Wing

Based on: Malone, J.F., Radiat. Prot. Dos., 135, 71–78, 2009.

From another perspective, the model for provision of medical services continues to harbour strong paternalist elements, while the public-ethics context within which it operates has changed radically. It is not uncommon to encounter evidence of desensitisation of professions to the concerns of the public. They sometimes fail to recognise that growth in individual autonomy, consumerist culture, transparency and accountability are dominant influences in the way social (including medical) transactions are expected to take place. Failures in these areas have led to distrust of the authority of professions, and have ultimately, in some countries, led to the collapse of professional self-regulation (GMC 2008). Examples of these phenomena can be studied in the history of various medical scandals, such as: the fatal problems with blood products, the Harold Shipman Enquiry in the UK, the infant organ retention issues and many others (National Archives 2009). Table 1.2 lists some of the ma...

Índice

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• About the Series
• Preface
• Authors
• CHAPTER 1 ▪ Introduction
• CHAPTER 2 ▪ Ethics for Radiation Protection in Medicine: Framework and Multicultural Considerations
• CHAPTER 3 ▪ The Pragmatic Value Set: Contexts and Application to Radiation Protection in Medicine
• CHAPTER 4 ▪ Ethics Analysis of Imaging Scenarios
• CHAPTER 5 ▪ Ethics Analysis of Radiotherapy Scenarios
• CHAPTER 6 ▪ Extension of the Pragmatic Value Set
• CHAPTER 7 ▪ Reflections on Uncertainty, Risk and Fairness
• AFTERWORD
• REFERENCES
• APPENDIX
• INDEX