IRA, Lausanne University Hospital Ethical components in ...icrp.org/docs/2/7. Ethical components in...
Transcript of IRA, Lausanne University Hospital Ethical components in ...icrp.org/docs/2/7. Ethical components in...
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Ethical components in
radiological protection
Prof François Bochud
IRA, Lausanne University Hospital
radiological protection
communication:
first feedbacks from
Switzerland1st European Workshop on the Ethical Dimensions
of the Radiological Protection System
Milano 16-18 December 2013
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Moral philosophy
deontology
duty coming from
"above"
virtue
the actors can be
judged from their
utilitarianism
the actions are
judged by their
actor
"above"
categorical imperative,
god, etc.
judged from their
actions
judged by their
consequences
action consequences
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Moral philosophy
deontology virtue utilitarianism
actor action consequences
no approach is intrinsically superior to another
these are useful resources for specific reasoning depending on the context
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Ethics history in medicine
international law document
Voluntary consent of research subjects
Freedom to withdraw for the subjects
Proficiency requirement of the researcher
48
Hu
ma
n r
igh
ts
Medical bioethics
Nu
rem
be
rg
1947
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Ethics history in medicineBelmont Report (1978)
Definition of basic ethical principles
• autonomy
• beneficence (non-maleficence)
• justice
48 1960
Challenging
traditions and
power ...
Medical bioethics
Ethical issues of
biotechnology
19901947 1978
Hu
ma
n r
igh
ts
Nu
rem
be
rg
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autonomy
beneficence
deontology
3 principles of bioethics
beneficence
(non-maleficence)
justice
deontology
utilitarianism
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autonomy
beneficence
deontology
Basis of free and informed consent
Prerequisite: ability to discern
All necessary information should
be available in order to build an
opinion in accessible and
understandable terms
beneficence
(non-maleficence)
justice
deontology
utilitarianism
Also:
Confidentiality
Duty of truthfulness
Medical confidentiality
End of paternalism
"Technical skills do not guarantee
moral skills"
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autonomy
beneficence
deontologyOverall good for both
the individual and society
beneficence
(non-maleficence)
justice
deontology
utilitarianism
Maximization of profit versus risks
Suppressing evil and relieve suffering
Promote the well-being and sustain life
Preserve health and prevent disease
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autonomy
beneficence
deontology
beneficence
(non-maleficence)
justice
deontology
utilitarianismAllocate resources equitably
Distribute fairly benefits and risks
No discrimination based on
ethnic criteria, racial, religious,
ideological, political, age, cost, etc..
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autonomy
beneficence
deontology
Acceptable mixing of the
principles comes from
virtue …and depends on the context
beneficence
(non-maleficence)
justice
deontology
utilitarianism
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Justification
deontology /
utilitarianism
3 principles of radiation protection
Optimization
Limitation
deontology
utilitarianism
103
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Justification
deontology /
utilitarianism
RADIATION DIAGNOSTIC
Level 1: justification of X-ray in medicine
Level 2: justification of the procedure
for a group of patients
Level 3: diagnostic and therapeutic objectives of
this patient require the procedure
105
Optimization
Limitation
deontology
utilitarianism
MORE GENERALLY
the Commission only recommends
that justification require that the
net benefit be positive
103
Justification concerns acting
with the right reasons and motives
(Hansson, J. Rad Prot 2007)
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Justification
deontology /
utilitarianism
Maximize good versus harm
RADIATION DIAGNOSTIC
Lowest dose compatible with the diagnostic and
therapeutic objectives (ALARA)
optimization is subordinated
to the justification principle
Optimization
Limitation
deontology
utilitarianism
to the justification principle
Image quality
level 1. technical efficacy
level 2. diagnostic accuracy
level 3. diagnostic thinking
level 4. therapeutic efficacy
level 5. patient outcome
level 6. societal efficacy
optimization
can be
performed at
different levels
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Justification
deontology /
utilitarianism
Optimization
Limitation
deontology
utilitarianism
Justification and Optimization are not
always sufficient
No individual should be abused to excess
A certain level of harm is unacceptable
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Justification
deontology /
utilitarianism
Acceptable mixing of the
principles comes from
virtue …and depends on the context
Optimization
Limitation
deontology
utilitarianism
…and depends on the context
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Practical exercise to see what this means
1. Small question with moral or ethical component
… poll
2. Rephrasing of the question in ethical perspective
3. Same question again
… poll
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Is it acceptable to perform radiological images of plane
passengers before boarding
(with x-ray backscattering systems)?
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Is it acceptable to perform radiological images of
plane passengers before boarding
(with x-ray backscattering systems)?
11
91. yes
2. no
3. I don't know
1. 2. 3.
63. I don't know
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x-ray backscattering systems
• Deontological arguments– The passenger receives a
supplementary dose that was not asked
– The passenger can ask for manual search
• Utilitarian arguments– Security increase for all
passengers
– Doses are very low(~0.050 uSv/scan)
• Milano-Los Angelesmanual search
– Safe for security officer• no contact,
less infection risk
– same situation for all passengers
• Milano-Los Angeles~140 uSv
• 12 s flight (according to AAPM)
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Is it acceptable to perform radiological images
of plane passengers before boarding?
17
1. yes
2. no
3. I don't know
Same question
1. 2. 3.
2
7
3. I don't know
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Is it acceptable to perform radiological images of plane passengers before boarding?
11
17yes
9
6
7
2
no
I don't know
Première diapositive Deuxième diapositive
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8283
51
Same question asked
to a general public
in November 2012,
after a presentation
of what we know
about risk
with no information,
deontological principles
seem to dominate:
"no x-rays for new
application!"
"x-rays are dangerous!"
The Swiss federal
aft
er
be
fore
aft
er
be
fore
aft
er
be
fore
YES NO don't know
46
9
51
3
with some information,
utilitarian principles can
overturn the original
opinion:
"with such low doses, ok"
The Swiss federal
commission for radiation
protection recommends
to ban such devices with
other utilitarian
arguments…
"trivializing back-scatter
x-rays would increase the
collective dose and
disseminate further
radiation use"
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Imagine that your house is close to nuclear power plant after an
incident similar to what happened in Fukushima.
A which annual effective dose would you leave your house?
8
1. 1 mSv/year
2. 5 mSv/year
3. 20 mSv/year
1. 2. 3. 4. 5. 6.
3
2
4
22
3. 20 mSv/year
4. 50 mSv/year
5. 100 mSv/year
6. more than 100
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At which annual effective dose would you leave your house?
7
1. 1 mSv/year
2. 5 mSv/year
3. 20 mSv/year
annual limit
population
we get
each year
Same question
1. 2. 3. 4. 5. 6.
2
3
4
1
43. 20 mSv/year
4. 50 mSv/year
5. 100 mSv/year
6. more than 100we get
in 20 years
each year
annual limit
professional
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At which annual effective dose would you leave your house?
3
2
8
2
3
7
1 mSv/year
5 mSv/year
20 mSv/year
2
2
4
7
4
1
4
50 mSv/year
100 mSv/year
more than 100
Première diapositive Deuxième diapositive
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Same question asked to radiation oncologists in June 2011,
In their profession life,
radiation oncologists
• are ready to accept only
slightly optimized medical
images
1 m
Sv/a
2 m
Sv/a
5 m
Sv/a
10
mSv
/a
20
mSv
/a
50
mSv
/a
10
0 m
Sv/a
20
0 m
Sv/a
50
0 m
Sv/a
• commonly consider as
negligible overdosages
of 500 mGy of organ at risk
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Same question asked to a general public in November 2012,
after a presentation of what we know about risk
1 m
Sv/a
20
mSv
/a
50
mSv
/a
10
0 m
Sv/a
> 1
00
mSv
/a
5 m
Sv/a
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As a person working with radiations,
would you like to know if you are
genetically more radiosensitive?
211. yes
2. no
3. I don't know
1. 2. 3.
24
3. I don't know
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I want to know for myself if I am more
radiosensitive
• Deontological
arguments
– Everybody has the right
• Utilitarian arguments
– These genetic tests just
give a probability– Everybody has the right
to know
– Accepting a risk can only
be done with informed
knowledge
give a probability
• this would help you
balance the pro and con
– Once you know, you
start worrying
• anti-placebo effect
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I want to know if I am genetically more radiosensitive
17
1. yes
2. no
3. I don't know
Same question
1. 2. 3.
1
7
3. I don't know
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I want to know if I am genetically more radiosensitive
21
17yes
4
2
7
1
no
I don't know
Première diapositive Deuxième diapositive
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Slightly different question
I want to know if my employees are more radiosensitive
17
1. yes
2. no
3. I don't know
1. 2. 3.
0
93. I don't know
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I want to know if my employees are more
radiosensitive
• Deontological arguments
– I need to be able to
• Utilitarian arguments
– It is better to submit the – I need to be able to protect my employees
– I cannot discriminatebetween people when I choose a new employee
– It is better to submit the most resistant people to a given risk
– It is accepted to act this way with pilots and firefighters who should have good eyesight and physical shape
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I want to know if my employees are more radiosensitive
16
1. yes
2. no
3. I don't know
Same question
1. 2. 3.
2
6
3. I don't know
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I want to know if my employees are more radiosensitive
17
16yes
9
0
6
2
no
I don't know
Première diapositive Deuxième diapositive
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NO
don't knoww
an
ts t
o k
no
w
Coherence between the two opinions: whether I or my
employer wants to know, I agree or I don't
(about 50 RP experts in Switzerland in December 2013)
YES NO don't know
I want to know for myself
YES
NO
OK
if m
y e
mp
loy
er
wa
nts
to
kn
ow
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There are some hints that a particular gene increases the
risk of leukemia by a factor 25.
If this were confirmed, do you think that people with this gene
should be excluded from occupational exposure?12
91. yes
2. no
3. I don't know
1. 2. 3.
63. I don't know
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It is proven that personal behavior, like tobacco, has a direct
effect on radiosensitivity.
Do you think that tobacco smokers should be excluded from
occupational exposure?
221. yes
2. no
3. I don't know
1. 2. 3.
2 2
3. I don't know
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(opinions of about 50 RP experts in Switzerland collected in December 2013)
Utilitarian approach typical for genetic risk and medical treatment in general:
"one cannot do much against this; let's act with precaution"
"weak or frail people need special protection"
YES NO don't know
Exclude if leukemia risk is 25 times higher
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NO
don't know
smo
ker
(opinions of about 50 RP experts in Switzerland collected in December 2013)
Those who said no for a
genetic reason
continued to say no for
a behavioral reason
YES NO don't know
Exclude if leukemia risk is 25 times higher
YES
NO
Exc
lud
e i
f to
ba
cco
smo
ker
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NO
don't know
smo
ker
Deontological approach typical for risk
linked to behavior:
"everybody has the right to behave as
long as this does not impede on
others' freedom"
(opinions of about 50 RP experts in Switzerland collected in December 2013)
YES NO don't know
Exclude if leukemia risk is 25 times higher
YES
NO
Exc
lud
e i
f to
ba
cco
smo
ker
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Conclusion
• Ethical principles are enshrined in radiation protection and in medicine– autonomy, benevolence, justice [bioethics]
– justification, optimization, limitation [radiation protection]
• Ethical decisions need to be taken with the help of different schools of moral philosophy– First define what we want– First define what we want
• Virtue helps to define priorities according to the context(e.g. protect an individual or a population ; now or future ; etc.)
– Then mix deontology and utilitarianism• Deontology appears to have some primacy
– Autonomy in Western medicine
– Justification in radiation protection
• Some dose of utilitarianism is always used in practice
• Ethics and radiation protection are dynamic– What is tolerable now may well be different than what it was in 1950
– What is tolerable here may well be different than what it is there