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ing and electrophysiological treatments are apt examples(13). Table 1. Some popular medical TV dramas. List of medical soaps on TV. Holby City. The Clinic.
Radiation Protection Dosimetry Advance Access published March 5, 2009 Radiation Protection Dosimetry (2009), pp. 1–8

doi:10.1093/rpd/ncp010

RADIATION PROTECTION IN MEDICINE: ETHICAL FRAMEWORK REVISITED J. F. Malone* St James’s Hospital and Trinity College Health Sciences Centre, Dublin 8, Ireland

The ethical framework within which medicine operates has changed radically over the last two decades. This has been stimulated by events leading to controversy, such as the infant organ retention scandals; concerns about blood products; self regulation of medical practice in the wake of the Harold Shipman Enquiry in the UK; and many other events. It has become obvious following investigations and/or public enquiries that a gap has opened up between what is acceptable to the public on the one hand, and what appears reasonable to, or is at least accepted by, the professionals involved on the other. This paper reviews these issues and some conclusions of a workshop held to consider them. It places the developments in the context of the idea that the approach to problems and communication in a group of people/professionals such as doctors, radiologists, radiation protection specialists, or even the general public may be regarded as a ‘culture’. Current practice of radiation protection in medicine is examined in the light of these considerations.

INTRODUCTION This paper should be read in association with another by Malone(1). Both papers complement each other; the combined material was used to set the scene for both a workshop held in Dublin and the special session of the final SENTINEL Delft conference devoted to Ethics(2). This paper has been updated to reflect advances in thinking since the workshop, particularly those arising from the Delft Conference and recent International Atomic Energy Agency (IAEA) consultations. Radiology has seen enormous growth in the last two generations. Many clinical procedures, practices and equipment types that are now commonplace did not exist in the 1980s. Yet the fundamental ethical basis for these practices has not seen a corresponding level of engagement. Areas of concern that come to mind include, for example, issues around justification, communication with patients, the knowledge base of referring physicians and radiologists on radiation risks, consent/authorisation to undertake procedures, inadvertent irradiation of the foetus/ embryo during pregnancy and many more. Critical to these concerns are the diverging attitudes and approaches that now characterise the professions and the general public, and the possibilities inherent in this divergence for serious misunderstandings and/or conflict. The divergence has, for example, changed the ground rules to be observed in Europe when conducting clinical research(3). In some countries it has also changed the system of governance for the medical professiona. *Corresponding author: [email protected] a For example, the new arrangements for the medical council, the governing body for doctors in the UK, are such that the profession is no longer policed mainly by

In this paper, the framework or ‘culture’ out of which the professions operate is considered from a point of view often taken by anthropologists, ethnographers or social scientists(4,5). A comment on the use of the term ‘culture’ in this context is provided in the next section. Thereafter this framework is used to look at the professions of medicine, radiology and radiation protection and gain a new perspective on how we handle some issues of ethical importance.

CULTURE AND PROFESSIONS 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 studies of the way of life and culture of disadvantaged subgroups. However, a similar methodology can be applied to any identifiable group to expose the culture out of which it operates. The group might be, for example, clerics, doctors, software workers, or other professions, including radiation protection specialists. In these studies the term culture is much broader than that implied when it is used to denote some aspects of the arts. Wilson, in a study of the decline of a highly identifiable group (clergymen), describes culture as follows(6): itself. Fifty per cent of the council must, by law, be lay. Similar provisions prevail or are emerging in other countries.

# The Author 2009. Published by Oxford University Press. All rights reserved. For Permissions, please email: [email protected]

J. F. MALONE

[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(7). It is clear that these characteristics can be applied to many groups, including those working in medicine and radiology, radiation protection professionals, regulators and the general public. Each group has, to some extent, the characteristics described by Wilson and many other workers 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, that is, will live according to the culture of the group. MEDICINE, RADIOLOGY, RADIATION PROTECTION, PUBLIC LIFE AND POPULAR CULTURE Modern medical practice is so multifaceted that it defies comprehensive description. Possibly the simplest measure of its importance and impact is the scale of investment in it in developed countries, both in financial and human termsb. 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 b

In many developed countries the investment is in the range of 8– 15% of GDP (and sometimes even higher). Available at http://fiordiliji.sourceoecd.org/pdf/ society_glance/25.pdf.

population. Investment on this scale can only occur when the community regards it as important; this is certainly the case with medicine/healthcare. 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 is needed(1,8,9). Thus medicine is clearly an important part of the culture out of which we live our lives. The arguments favouring this view include those mentioned above but also, perhaps more interestingly, include the number of medical dramas (‘soapoperas’) that appear on television (see Table 1). When human societies do not fully understand what is happening in an area, they create and tell stories that carry some (or all) of the meaning that cannot be more conventionally articulated(10,11). The position of medical soaps reflects this deep human characteristic, and our flawed understanding of the healthcare system and our expectations of it. 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, e.g. that by Damien Hirst (12). Other more obvious characteristics include the enormous technological successes of medicine, and the social challenges being mounted to the way it is practiced. Both are proceeding together, almost hand in hand in developed countries. Instances of medical progress are too numerous to mention, but in this context, perhaps minimally invasive surgery and cardiac interventional procedures such as stenting and electrophysiological treatments are apt examples(13).

Table 1. Some popular medical TV dramas. List of medical soaps on TV Holby City Casualty ER The Royal Grey’s Anatomy Scrubs

The Clinic Silent Witness Dr Finlay’s Casebook Waking the Dead Green Wing

Table 2. When Medical Practice Model fails. When Medical Practice Model fails Shipman deaths in the UK Blood products scandal Organ retention scandal Collapse of self-regulation The dawn raid, a salutary incident

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On the other hand, the challenges to medicine include those listed in Table 2. This has been expanded on in Malone(1). The last entry is an oblique reference to the early morning arrest, at their homes, of two senior well-established professionalsc. They were then charged with serious crimes that resulted in patients dying. What was unusual about this is that both are/were well regarded by their peers, i.e. within the culture of their professions. Many were shocked by the charges, and felt that both had conducted themselves according to the standards the profession expected at the time. However public enquiry and formal judicial investigation did not reach similar conclusions and was highly critical of both. The charges involved were eventually not pursued(14 – 17). This is not a unique happening and similar shock has characterised professional reactions to the conclusions reached by public enquiries an example of this is the initial reaction of pathologists to the public reaction to the organ retention enquiries. Radiology has struggled valiantly to establish its position within medicine and has fostered its expertise to protect a constantly shifting position. Radiologists are often the sole custodians of, and gatekeepers to, specialist knowledge on how to protect patients and staff from the hazards of radiation. This has generally been used to good effect and, as might be expected, is also employed opportunistically in defence of the discipline in the inevitable turf battles that erupt from time to time. There are many commendable aspects of the contributions of radiology to the implementation of a good radiological protection agenda; there are also some weaknesses. One of the more important of these is the weakness of the justification process in much of diagnostic radiology. In combination with the absence of dose limits for diagnostic medical exposure, this could be hard to defend as reasonable to the average person(1). As will be seen below, this has emerged as an area of major concern. Other specific concerns about consent/authorisation; irradiation of potentially pregnant females, and criteria for selection of patients for high dose or expensive procedures are discussed or reported elsewhere(1,18,19). A major difficulty in the post modern era is getting engagement from scientists and doctors in the debate on ethical and related issues. In the English language this reflects, what some see as, trivialisation of these debates so that they appeared to be language games for much of the period between and following the two world wars. While the language games persist, there is now excellent accessible work being produced that provides a basis for ethical debate and education(19 – 22). Ethical concerns c The Medical Director and Principal Biochemist of the Irish Blood Bank.

are also evident in the social sciences, formal ethical studies, public discourse and literature, some of it heated, but much of it accessible(23 – 25). The picture that emerges generally finds public life to be dominated by moves to individualism and individual autonomy in a society with a strong consumerist approach. Medicine and medical services inevitably experience these influences. It is clear that the consumerist approach is already present in patterns of provision even in socialised medical systems. In addition, for example, medical and dental tourism are gaining ground in many parts of the worldd,(26). Likewise, litigation and distrust of authority, which is a growing feature of western medicine, is at least in part due to the failure of physicians to respect the individual autonomy of patients and to communicate and be appropriately transparent and accountable to them(27,28). A full discussion of these issues is beyond the scope of this papere. Further discussion here is limited to aspects of communication, aspects of justification and aspects of non medical/medico legal exposures.

COMMUNICATION AND THE CULTURE OF RADIATION PROTECTION It is clear from some of the above examples that there is a failure of communication and of trust between the public and the professions involved in medicine in some circumstances. This is quite evident when the breach between the two is major and results in events or scandals requiring public enquiry or the intervention of legal proceedings. However, even in less severe disputes involving the public and professions, for example, those involving public health programmes, fluoridation of the water supply, measles, mumps and rubella vaccination of children, Creutzfeldt–Jakob disease or road accidents, there is evidence that the public approach risk in a fashion that differs from the approach adopted by the professions(29). The public often finds the professionals’ approach[es] unconvincing or at least are often unconvinced by them. There is considerable literature from the social sciences to this effect (30). For example, Alaszewski and Horlick-Jones find the professions rely on providing more complete information on comparative risks when they wish to convince the public. On the other hand, they state there is little evidence to endorse the effectiveness of this approach. This is, perhaps, clearly illustrated in the response, particularly of younger people, to the d For example the cover story in the European edition of Newsweek magazine was devoted to medical tourism recently. e Further discussion is available in ref. (1) and the rest of these proceedings.

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evidence presented in anti-smoking or safe sex campaigns based only on risk. However, there is also evidence that provision of risk information may have more impact when the effectiveness of protective actions is emphasised, when psychological work on behaviour is employed and when the social context of peoples’ lives is taken account of(29). Alaszewski and Horlick-Jones also conclude that the factors in Tables 3 and 4 are those influencing the response to risk information. Even a cursory review of these establishes that radiation protection specialists pay little attention to them. Further, Alaszewski and Horlick-Jones conclude that in practice we do little to use the body of knowledge available when it comes to communicating and managing issues associated with health risks. We continue, despite the evidence, to work on the assumption that the target audience consists of individuals who will review the evidence and both identify and choose the course of action that will maximise health gain. However, Alaszewski and Horlick-Jones are of the view that using knowledge of the impact of trustworthiness, social context and other influences could greatly help us in these tasks. The special language of radiation protection does little to encourage trust or to help relate to the social context. In addition we add confusion to the mixture as, almost uniquely in science, we use the same name for the unit of two separate quantitiesf. In an area susceptible to both conceptual difficulties and confusion this is an unpardonable lapse in the duty to communicate. Such an opaque and confusing approach is unlikely to lead to understanding, inspire trust, or lead to effective communication in a social context. It unnecessarily adds to the lack of trust that applies to radiation because of its unfortunate historical associations and general mistrust of government; in consequence it compounds problems of transparency and accountability in the public domain. Communicating effectively will require a commitment to re-evaluate what is needed if we aspire to reaching beyond the mistrust arising from medical scandals and the generalised mistrust of authority, radiation and the nuclear industry. Yet this is

f

The extent of the impenetrability of the system of radiation units and measurements is well illustrated by the fact the same name (Sievert) is used for two completely different quantities. Evidence of this impenetrability is was provided in a study which illustrated that from a group of doctors surveyed, none knew the quantity in which the dose from a chest x-ray should be specified (see below). It is also indirectly attested to by the news reportage on the 2006 Polonium poisoning incident in London, in which the news coverage avoided mention of effective dose, or equivalent dose, which radiation professionals generally use as the denominators for risk http://news.bbc.co.uk/1/hi/ uk/6179074.stm.

Table 3. Factors influencing response to information on risk. Factors influencing response to information on risk Level of trust in the information source Relevance to everyday life Relation to other risks The fit with previous knowledge/experience Difficulty/importance of the options/decisions

Table 4. Improving communication. Improving communication Build trusting relationships Become attuned to the multiple, conflicting sources of information that patients consult Become attuned to the psychosocial factors influencing patients’ responses

probably necessary to allow a healthy future for medical imaging. Failure to appreciate this will almost certainly lead to inadequate transparency, and a sense of accountability that will inevitably be flawed and furtive, even when everything else is well ordered. JUSTIFICATION AND THE CULTURE OF RADIATION PROTECTION The foundational principles of radiation protection in diagnostic radiology include Justification, ALARA, and the use of Dose Limits or Constraints as appropriate(31,32). Many justification issues arise in radiology once current practice is examined. Only two can be described here, but many others remain to be raised and treated elsewhere in due course. The two raised here are the question of the knowledge of the physician requesting or conducting the examinations and, on the other hand, the extent to which the examinations undertaken appear to be justified in the view of the limited group of workers that have considered the question. Knowledge of the physician A small number of publications have raised questions about the level of knowledge of physicians in general and radiologists in particular with respect to the risk involved in particular examinations. For example, Shiralkar et al. demonstrated that over 97% of doctors in two hospitals in the UK underestimate the dose and risk from common examinations, including computed tomography (CT)(33). They state that ‘it seems that most doctors have no idea as to the amount of radiation received by patients’. The participants included 50 Consultants

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and 80 more junior doctors, none of whom knew the dose from a chest x-ray or the unit in which it is specified. The sample included 10 consultant radiologists all of whom had received courses in radiation protection. This raises two issues, neither of which it is wise to ignore. The first relates to the effectiveness of communication of information in radiation protection and has already been mentioned. The second relates to worries about the capacity of physicians or radiologists to make informed judgements on justification of medical radiological examinations, something the system of medical radiation protection is predicated on. The findings of Shiralkar et al. have been confirmed qualitatively by a number of other workers(34,35). There is also the probability that the consequent, possibly poorly informed, communication between physician and patient about dose and risk may, on occasions, be patronising, inaccurate or inadequate(26,34,36). This is increasingly problematic with the advent of routinely high CT doses and the prevailing public culture of personal autonomy. It also raises the issue of consent and the manner in which it is obtained. A valid consent (explicit or implied) is not possible without proper and appropriate communication of risk; such seems unlikely if professionals are poorly informed. Concerns have been raised about the sustainability of some current facets of medical imaging practices, particularly those involving higher doses. Informed consent must surely be one such area(36,37). For a valid consent, full appropriate disclosure respecting the patient’s rights and autonomy, as well as adequate communication are essential(36,37 – 40). These issues acquire even more force when the patient is pregnant or possibly pregnant (41 – 43). In radiology and radiation protection the primacy of these considerations has, arguably, been lost sight of. This makes dealing with the issues involved in high-dose CT, and interventional procedures, highly problematic. Extent to which examinations undertaken appear to be justified Some practitioners and radiation protection specialists feel that a significant fraction of the examinations requested and undertaken cannot be justified on clinical grounds, even on the most generous interpretation of the term. The figures cited vary from 20 to 50% of the examinations performed(39,44,45). The precise figure is unknown and probably varies with location, requesting physician or prescriber, practitioner, availability of other modalities, quality of training and a number of other factors. For example, general practitioners and community physicians will probably differ from hospital physicians. It is also likely that there are differences between specialties. Studies to date, including audit against benchmarks for justification, such as the Royal

College of Radiologists referral criteria, are relatively rare(46). However such limited data as is available show, in specific circumstances, that: † roughly 50% of physicians in two well-established teaching centres are unaware of the referral criteria for many common examinations(45,47); † audit is an effective tool in improving compliance of general practitioners with justification(48); † a 44% CT dose reduction can be achieved in trauma cases where referral criteria are followed(49) and † a straw poll of radiologists suggests that 33% of paediatric examinations are unnecessary(50). These and other studies, when taken with the considered opinions of experienced practitioners, suggest that the pattern of practice in the west appears to be one of systematic over usage with a poor level of attention to justification. Additional issues occur in special cases where there is a generic doubt about justification such as in situations involving self-referral by patient or practitioner, inadequately validated screening programmes and human exposures undertaken for non-medical reasons, such as those mentioned below. In the main these are beyond the scope of this publication, but are raised elsewhere(43,51,52). NON-MEDICAL HUMAN EXPOSURES AND THE CULTURE OF RADIATION PROTECTION The precise definition of medical exposure is not completely determined. For example, in the European Union (EU) and in IAEA publications it is taken to include medico-legal exposures and the exposure of comforters and carers. There are in addition many other types of human exposure undertaken for a variety of reasons, which include determination of individual demographic data, security, theft detection, public health surveillance, drugs searches, forensic enquiry, self referred procedures and many more. While these activities may require examinations similar or identical to medical radiological procedures, their justification is seldom medical as, in many cases, they are not for the benefit of the individual involved. Hence the issue of their enjoying the privileged position accorded to medical exposures (e.g. no dose limit) inevitably raises itself. It is particularly important that this issue be dealt with, as the credibility of the exemption of medical exposures from dose limits is likely to depend on their not being confused, in the minds of legislators, with some of these activities. The EU has undertaken a useful, if incomplete, analysis of this area, which has resulted in the publication of a conference proceedings and a separate paper is devoted to the area in this proceedings(43,52).

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CONCLUSION

REFERENCES

The defining aspects of radiation protection, as exemplified by the agencies whose main responsibility it is, are a strong legal and a strong scientific basis. It is important to be aware that the conceptual and/or standards-legal framework employed by organisations such as International Commission on Radiological Protection (ICRP), the IAEA, the EU and the United Nations Scientific Committee on Effects of Atomic Radiation has been developed mainly outside of medicine, in disciplines where the fundamental impulse is different to and may even be at variance with the drivers for medicine. For example, the competing requirements of transparency and security, or accountability and need for freedom of action may be positioned differently in nuclear safety and in medicine. This issue and its implications have been more fully discussed elsewhere, although it could be profitably be explored more extensively still(1). The radiation protection system, at the level of ICRP, the IAEA, the EU, legislators and regulators is in fact a system that tries valiantly to create an arranged marriage between data and risk estimates on the one hand and value judgements on behalf of the community on the other. The lack of engagement of these bodies with those involved with the social sciences and humanities creates a situation where the philosophy out of which radiation protection is operating has becomes dated and trapped in the era in which its defining approach was set down. This can give rise to a distance between the concerns of the culture of radiation protection and the wider cultures of the public, medical practice and groups of patients, whose concerns are reflected in the popular culture of the time. The 1970s provided one of the more recent great debates between the sciences and the humanities, culminating in CP Snow’s ‘Two Cultures’ essays(53). In grappling with the problems raised here the radiological and radiation protection communities/ cultures face issues on which there is much to learn from the humanities, provided time is taken to notice what is there to be shared and availed of. Both professionals and the public are more likely to accept and comply with a framework devised and implemented in tune with the philosophical assumptions/background of the day, and which uses an up-to-date approach to risk communication.

1. Malone, J. F. New ethical issues for radiation protection in diagnostic radiology. Radiat. Prot. Dosim. 129(1– 3), 6 –12 (2008), 10.1093/rpd/ncn012. 2. Faulkner, K., Schultz, F. W. and Zoetlief, H., Eds. Safety and efficacy for new techniques and imaging using new equipment to support European Legislation. Radiat. Prot. Dosim. 129, 358 pp. (2008) (special issue). 3. Schreiner-Karoussou, A. Review of existing issues, ethics and practices in general medical research and in radiation protection research. Radiat. Prot. Dosim. 129(1– 3), 303–306 (2008), 10.1093/rpd/ncn146. 4. Bryman, A. Ethnography and participant observation Chapter 14. In: Social Research Methods (Oxford: Oxford University Press) (2001). 5. Fulcher, J. and Scott, J. Sociology (Oxford: Oxford University Press) (1999). 6. Wilson, G. B. Clericalism: The Death of Priesthood (Collegeville, Minnesota: Liturgical Press) (2008). 7. Wilson, J. Clericalism: The Death of Priesthood (Collegeville, Minnesota: Liturgical Press) pp. 3–9 (2008). 8. Malone, J. Images and reflections on the school’s theme: orthodoxies and heresies in science, medicine and popular culture. In: The New Ireland and its Sacred Cows: Orthodoxies and Heresies at the Merriman Summer School 2004. Malone, J. Ed. (Dublin: The Liffey Press) pp. 9 –26 (2005). 9. Malone, J. Ed. The New Ireland and its Sacred Cows: Orthodoxies and Heresies at the Merriman Summer School 2004. (Dublin: The Liffey Press) 193þxi pp. (2005). 10. Mc Adams, D. P. The Stories We Live By: Personal Myths and the Making of the Self (New York and London: The Guilford Press) (1993). 11. Shea, J. Stories of God: An Unauthorised Biography (Chicago: The Thomas More Press) (1978) and Booker, C. The Seven Basic Plots: Why We Tell Stories (London and New York: Continuum) 728 pp. (2004). 12. Steak and Kidney Pie, from Damien Hirst’s “The Last Supper Series”. Tate on line. Available on http://www. tate.org.uk/servlet/ViewWork?cgroupid=999999961& workid=26766&searchid=10034&tabview=text and Economic Expert.Com at http://www.economicexpert. com/a/Damien:Hirst.htm (both accessed on 29/12/ 2008). 13. Biondi-Zoccai, G. G. L., Abbate, A., Agostoni, P., Testa, L., Burzotta, F., Lotrionte, M., Trani, C. and Biasucci, L. M. Long-term benefits of an early invasive management in acute coronary syndromes depend on intracoronary stenting and aggressive antiplatelet treatment: a metaregression. Am. Heart J. 149(3), 504– 511 (2005). Available on http://linkinghub.elsevier.com/ retrieve/pii/S0002870304007781 14. Di Mario, C. and Sutaria, N. Coronary angiography in the angioplasty era: projections with a meaning. Heart 91(7), 968–976 (2005). 15. Mac Cormaic, R. Director of Public Prosecutions (DPP) drops case over hepatitis C infections scandal. Irish Times, 13 December 2008. Available on http:// www.irishtimes.com/newspaper/ireland/2008/1213/ 1229035663522.html and Case against biochemist dropped. RTE News Report. Available on http://www. rte.ie/news/2008/1212/hepatitisc_av.html?2462554,null,

FUNDING This work was conducted partially within the frame of the European Commission 6th Framework Programme SENTINEL Contract No FP6 – 012909.

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16. 17.

18. 19. 20.

21. 22. 23. 24. 25. 26. 27. 28.

29.

30.

31. 32. 33.

34.

230 (both accessed on 29/12/2008). Charging and arrest of participants in Dawn Raid. 2008. Irish Independent, 7th Feb 2007. For background: http:// positiveaction.ie/history.html DOHC (Department of Health and Children). Report of the Expert Group on the Blood Transfusion Board (Dublin: The Stationery Office) (1995). DOHC (Department of Health and Children). Report of the Tribunal of Inquiry into the Infection with HIV and Hepatitis C of Persons with Haemophilia and Related Matters (Dublin: The Stationery Office) (2006). Online available on: http://www.dohc.ie/ publications/lindsay.html (accessed 1 May 2007). Corbett, R. and Corbett, R. Ethical issues, justification, referral criteria for budget limited and high dose procedures. Radiat. Prot. Dosim. 2009 (in press). Durand-Zaleski, I. Organisations and delivery of imaging services: The contribution of ethics and political economy. Radiat. Prot. Dosim. 2009 (in press). Sia, S. Ethical issues in radiology: a philosophical perspective. Also see, Justification and radiology: some ethical considerations. Radiat. Prot. Dosim. 2009 (in press). Warnock, M. An Intelligent Person’s Guide to Ethics (London and New York: Duckworth Overlook) (1998). Wolpert, L. The Unnatural Nature of Science (London and Boston: Faber and Faber) 1992. McEwan, I. Saturday. (London: Jonathan Cape) (2005). Dawkins, R. The God Delusion (London: Black Swan) (2007). Sheehan, M. Ethics and policy: dealing with public attitudes. Radiat. Prot. Dosim. 129(1–3), 295–298 (2008), 10.1093/rpd/ncn044. Hunter, N. Consent and communication: a commentary. Radiat. Prot. Dosim. (2009) (in press). Hogan, L. Ethical issues in radiology: perspectives from the Christian tradition. Radiat. Prot. Dosim. (2009) (in press) Hoffman, B. and Lysdahl, K. B. Moral principles and medical practice: the role of patient autonomy in the extensive use of radiological services. J. Med. Ethics 34, 446 –449 (2008). Alaszewski, A. and Horlick-Jones, T. How can doctors communicate information about risk more effectively? BMJ 327(7417), 728– 731 (2003), 10.1136/bmj.327. 7417.728. Bellaby, P. Communication and miscommunication of risk: understanding UK parents’ attitudes to combined MMR vaccination. BMJ 327(7417), 725– 728 (2003), 10.1136/bmj.327.7417.725. ICRP. Radiological protection in medicine, Publication 105. Ann. ICRP 37(6), 1–63 (2007). ICRP. The 2007 Recommendations of the International Commission on Radiological Protection. ICRP Publication 103. Ann. ICRP 37(2–4), 1 –332 (2007). Shiralkar, S., Rennie, A., Snow, M., Galland, R. B., Lewis, M. H. and Gower-Thomas, K. Doctors’ knowledge of radiation exposure: questionnaire study. BMJ 327(7411), 371– 372 (2003), 10.1136/bmj.327.7411.371. Lee, C. I., Haims, A. H., Monico, E. P., Brink, J. A. and Forman, H. P. Diagnostic CT scans: assessment of patient, physician, and radiologist awareness of radiation

35. 36.

37.

38.

39. 40. 41.

42.

43.

44.

45. 46.

47.

48.

49.

50.

dose and possible risks. Radiology 231(2), 393– 398 (2004). Soye, J. A. and Paterson, A. A survey of awareness of radiation dose among health professionals in Northern Ireland. Br. J. Radiol. 81, 725–729 (2008). Picano, E. Informed consent and communication of risk from radiological and nuclear medicine examinations: how to escape from a communication inferno. BMJ 329(7470), 849– 851 (2004), 10.1136/ bmj.329.7470.849. Shulman, M. Facing a CT scan? Think about radiation. US News and World Report (30 May 2008). Available on http://health.usnews.com/articles/health/cancer/ 2008/05/30/facing-a-ct-scan-think-about-radiation. html (accessed 29 December 2008). Baskerville, J. R. Screening patients with multi-detector computed axial tomography (MDCT): when will we inform patients about risks of radiation. Emerg. Med. J. 25(8), 323–324 (2008). Brenner, D. J. and Hall, E. J. Current concepts – computed tomography – an increasing source of radiation exposure. N. Engl. J. Med. 357, 2277–2284 (2007). IAEA. Report of justification 1 meeting. This Proceedings (2009). Schreiner-Karoussou, A. Review of existing issues and practices with respect to irradiation of patients and staff during pregnancy. Radiat Prot. Dosim. 129(1–3), 299–302 (2008). Ratnapalan, S. et al. Physicians’ perception of teratogenic risk associated with radiography and CT during early pregnancy. Am. J. Roentgenol. 182, 1107–1109 (2004), 10.1093/rpd/ncn145. EU. Medico-legal exposures, exposures with ionising radiation without medical indication. Proceedings of the International Symposium (Luxembourg: European Commission, DG TREN) (2003). Shulman, M. The doctor says get a CT scan. Should you? US News and World Report (28 November 2007). Available on http://health.usnews.com/articles/health/ 2007/11/28/the-doctor-says-get-a-ct-scan-should-you. html (accessed 29 December 2008). Mankad, K. and Bull, M. Awareness of “Making the best use of a department of clinical radiology” among physicians. Clin. Radiol. 60, 618–619 (2005). Royal College of Radiologists, R.C.R. Making the Best Use of Clinical Radiology Services: Referral Guidelines (London: Royal College of Radiologists) (2007). Kumar, S., Mankad, K. and Bhartia, B. Awareness of making the best use of a Department of Clinical Radiology among physicians in Leeds Teaching Hospitals, UK. Br. J. Radiol. 80, 140– 141 (2007). Eccles, M. et al. Effect of audit and feedback, and reminder messages on primary-care radiology referrals: a randomised trial. Lancet 357(9266), 1406–1409 (2001). Hadley, J. L., Agola, J. and Wong, P. Potential impact of the American College of Radiology appropriateness criteria on CT for trauma. Am. J. Roentgenol. 186, 937–942 (2006). Frush, D. R. Pediatric CT quality and dose: clinical perspective. In: From Invisible to Visible – The Science and Practice of X-ray Imaging and Radiation Dose

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J. F. MALONE Optimization. Frush, D. R. and Huda, W., Eds. (Oak Brook, Illinois: Radiological Society of North America) (2006). 51. Picano, E. Sustainability of medical imaging. BMJ 328(7439), 578–580 (2004), 10.1136/bmj.328.7439.578.

52. O’Reilly, G. and Malone, J. F. Ethical issues in medicolegal exposures. Radiat. Prot. Dosim. 129(1– 3), 307– 310 (2008), 10.1093/rpd/ncn087. 53. Snow, C. P. The Two Cultures and a Second Look (Cambridge: Cambridge University Press) (1964).

Page 8 of 8